NBBS1104 Management and Medico Legal Studies B

Faculty of Nursing and Allied Health Sciences
NBBS1104
Management and Medico
Legal Studies B
Copyright © Open University Malaysia (OUM)

NBBS1104
MANAGEMENT AND
MEDICO LEGAL
STUDIES B
Raijah A Rahim
Dr Khatijah Lim
Prof Madya Hjh Rohani Arshad

Project Directors: Prof Dato’ Dr Mansor Fadzil
Assoc Prof Raijah A Rahim
Open University Malaysia
Module Writers: Raijah A Rahim

Dr Khatijah Lim
Prof Madya Hjh Rohani Arshad
Universiti Malaya
Moderators: Prof Dr T K Mukherjee

Open University Malaysia (OUM)
Mariam Hj Mohd Nasir
Pusat Perubatan Universiti Malaya
Developed by: Centre for Instructional Design and Technology (CIDT)

First Edition, June 2007

Second Edition, December 2012 (rs)
Copyright © Open University Malaysia (OUM), December 2012, NBBS1104
All rights reserved. No part of this work may be reproduced in any form or by any means
without the written permission of the President, Open University Malaysia (OUM).

Table of Contents
Course Guide ix-xiv
Topic 1 Introduction to Management in Nursing 1

1.1 Process of Management 2
1.1.1 Planning 3
1.1.2 Organising 7
1.1.3 Staffing 7
1.1.4 Directing 10
1.1.5 Controlling 10
1.2 Management Theories 12
Summary 16
Key Terms 17
Self-Test 1 17
Self-Test 2 17
References 18
Topic 2 Leadership and Motivation 19

2.1 Interpretation of Leadership 20
2.1.1 Key Concept 23
2.1.2 LeadersÊ Characteristics 24
2.1.3 Transformational Leadership Competencies 24
2.1.4 Developing the Role of a Leader 27
2.1.5 The Nurse as a Leader 29
2.2 What is Motivation? 30
2.2.1 Motivation Theories 31
Summary 34
Key Terms 35
Self-Test 1 35
Self-Test 2 36
References 36
Topic 3 Managing the Ward and Clinical Area 37

3.1 Effective Staffing 38
3.1.1 Determination of Staffing Needs 38
3.1.2 Patient Classification System 40
3.2 Scheduling 44
3.3 Evaluation 45
Summary 47
Key Terms 47

iv TABLE OF CONTENTS
Self-Test 1 47
Self-Test 2 48
References 48
Topic 4 Models of Care Delivery System 49

4.1 Historical Perspective 50
4.2 Care Delivery Management Tools 55
4.2.1 Clinical Pathways 55
4.2.2 Case Management 57
4.3 Discussion (Group) 58
Summary 57
Key Terms 57
Self-Test 1 58
Self-Test 2 58
References 59
Topic 5 Managing Care 60

5.1 Effective Team Building 61
5.1.1 Stages of Team Process 61
5.1.2 Key Components of Effective Teams 63
5.2 Time Management 65
5.2.1 Time Management Strategies 66
5.2.2 Strategies to Enhance Personal Productivity 68
Summary 70
Key Terms 70
Self-Test 1 70
References 72
Topic 6 Decision Making 73

6.1 Factors Affecting Decision Making 74
6.2 Decision Making Theories 75
6.3 Decision Making Process 76
6.4 Group Decision Making 77
6.5 Critical Thinking 77
6.5.1 The Elements of Critical Thinking 79
6.5.2 Holistic Approach to Critical Thinking 80
6.6 Change and Conflict Resolution 81
6.6.1 The Change Process 82
6.6.2 Conflict 84
6.7 Managing Quality 89
6.7.1 Benefits of Quality Management (QM) 90
6.7.2 The Quality Improvement (QI) Process 90

TABLE OF CONTENTS v
Summary 91
Key Terms 92
Self-Test 1 92
Self-Test 2 93
References 94
Topic 7 Introduction to Law 96

7.1 Definition of Law 97
7.1.1 Sources of Law 97
7.1.2 The Malaysia Court Hierarchy 99
7.1.3 Differences between Malaysian Courts 100
7.1.4 Types of Law 103
7.1.5 Differences between Civil and Criminal Law 105
7.1.6 Tort Law 106
Summary 107
Key Terms 107
Self-Test 1 108
Self-Test 2 108
Topic 8 Introduction to Ethics 109

8.1 Standardisation of Professional Conduct 110
8.1.1 Licensure 110
8.1.2 Board of Nursing 111
8.1.3 Contract of Employment 112
8.2 What Kind of Law Apply to Nurses 113
8.2.1 Intentional and Unintentional Tort 115
8.3 Basic Ethical Concepts 116
8.3.1 Ethical Theories 117
8.3.2 Ethical Principles 117
8.4 Ethical Dilemmas 119
8.4.1 Ethical Decision Making Process 120
Summary 121
Key Terms 122
Self-Test 1 122
Self-Test 2 122

xxvi COURSE ASSIGNMENT GUIDE

COURSE GUIDE

COURSE GUIDE DESCRIPTION
You must read this Course Guide carefully from the beginning to the end. It tells
you briefly what the course is about and how you can work your way through
the course material. It also suggests the amount of time you are likely to spend in
order to complete the course successfully. Please refer to the Course Guide from
time to time as you work through the course material as it will help you to clarify
important study components or points that you might miss or overlook.
INTRODUCTION
NBBS1104 Management and Medico Legal Studies/Management and Medico
Legal Studies B is one of the courses offered by the Faculty of Nursing and Allied
Health Sciences at Open University Malaysia (OUM). This course is worth three
credit hours and should be covered over a period of 15 weeks.
COURSE AUDIENCE
This course is designed for students undertaking Bachelor of Nursing Sciences
(Hons) in OUM. There are no pre-requisites for this course. Students are required
to understand this course guide well before starting with the topics in this
module.
As an open and distance learner, you should be acquainted with learning

independently and being able to optimise the learning modes and environment
available to you. Before you begin this course, please ensure you have the right
course material and understand the course requirements as well as how the
course is conducted.
STUDY SCHEDULE
It is OUMÊs standard practice that learners should accumulate 40 study hours for
every credit hour. As such, for a four credit hour course, you are expected to
spend 160 study hours. Table I gives an estimation of how the 160 study hours
could be accumulated.

x COURSE GUIDE
Table 1: Estimation of Time Allocation of Study Hours
STUDY
STUDY ACTIVITIES
HOURS
Briefly go through the course content and participate in initial
3
discussions
Study the module 80
Attend four tutorial sessions 8
Online Discussion/Forum 42
Revision/Online Self-Test and Practice MCQ 24
Examination 3
TOTAL STUDY HOURS 160
LEARNING OUTCOMES
By the end of this course, you should be able to:
1. Explain what is management and leadership in nursing;
2. Describe the principles and processes of management;
3. Discuss the management and motivation theories in relation to nursing;
4. Differentiate the various models of care delivery system;
5. Appreciate time management for work and personal life; and
6. Discuss the types of law and legal issues in relation to nursing practice.
COURSE SYNOPSIS
This course is divided into eight topics. The course synopsis for each can be listed
as follows:
Topic 1: Managers tend to focus their energy and effort on ensuring smooth
workflow. Effective leaders view things globally, create visions of
what might be, inspire others, and are able to work with others in
more connected ways. In this topic you will explore the
management process, strategic planning, SWOT analysis and
management theories.

COURSE GUIDE xi
Topic 2: Leadership relies more on personality traits and people skills. All
professional nurses are leaders because they influence others. In this
topic, you will learn about leadership styles, methods of developing
the role of the leader and motivation theories.
Topic 3: A nurseÊs ability to provide safe and effective nursing care to

patients is dependent on the knowledge, level of
skills/competencies, attitude and experience of the staff, severity of
illness of the patients, the amount of nursing time available and
organisational support. This topic will explore these factors, how
they affect manpower planning, and the results of staffing plans.
Topic 4: Each nursing care delivery model has its advantages and
disadvantages and none is ideal. Some methods are conducive to
large institutions, whereas other systems may work best in
community settings. Managers in any organisation must examine
the organisational goals, the unit objectives, staff avaibility and the
budget when selecting a care delivery model. In this topic you will
explore the various types of care delivery system; functional
nursing, team nursing, primary nursing and patient-centred care.
Topic 5: Expert nurses deal with time management using contingency

planning. This planning includes rapidly assessing patient needs,
setting and shifting priorities. Expert nurses learn to anticipate and
prevent periods of extreme workload within a shift. In this module,
you will be provided with knowledge on team process, time
management for work and personal life.
Topic 6: Decision-making and critical thinking are vital skills for nurses
(expecially the nurse manager), as they not only involve managing
and delivering care, but are also essential in engaging planned
change. In this topic, you will learn problem-solving theories to
make good decisions as well as the concepts of quality assurance,
quality management, quality improvement and the change process.
Topic 7: The expanded role of professional nursing has forced new concerns
among nurses and a heightened awareness of the interaction of legal
and ethical issues. This topic will provide you with an overview of
the legal system and specific doctrines used by the courts to define
legal boundaries for nursing practices.
Topic 8: Having learnt the types of law and the differences between various
types of law in the previous topic, you will now study the standards

xii COURSE GUIDE
of professional conduct set by the Nursing Board Malaysia. In this

topic you will learn about the law that applies to nurses as well as
the legal issues, professional acts and regulations, employment rules
and ethical principles related to nursing.
TEXT ARRANGEMENT GUIDE

Before you go through this module, it is important that you note the text
arrangement. Understanding the text arrangement will help you to organise your
study of this course in a more objective and effective way. Generally, the text
arrangement for each topic is as follows:
Learning Outcomes: This section refers to what you should achieve after you
have completely covered a topic. As you go through each topic, you should
frequently refer to these learning outcomes. By doing this, you can continuously
gauge your understanding of the topic.
Self-Check: This component of the module is inserted at strategic locations

throughout the module. It may be inserted after one sub-section or a few sub-
sections. It usually comes in the form of a question. When you come across this
component, try to reflect on what you have already learnt thus far. By attempting
to answer the question, you should be able to gauge how well you have
understood the sub-section(s). Most of the time, the answers to the questions can
be found directly from the module itself.
Activity: Like Self-Check, the Activity component is also placed at various

locations or junctures throughout the module. This component may require you
to solve questions, explore short case studies, or conduct an observation or
research. It may even require you to evaluate a given scenario. When you come
across an Activity, you should try to reflect on what you have gathered from the
module and apply it to real situations. You should, at the same time, engage
yourself in higher order thinking where you might be required to analyse,
synthesise and evaluate instead of only having to recall and define.
Summary: You will find this component at the end of each topic. This component
helps you to recap the whole topic. By going through the summary, you should
be able to gauge your knowledge retention level. Should you find points in the
summary that you do not fully understand, it would be a good idea for you to
revisit the details in the module.
Key Terms: This component can be found at the end of each topic. You should go
through this component to remind yourself of important terms or jargon used

COURSE GUIDE xiii
throughout the module. Should you find terms here that you are not able to
explain, you should look for the terms in the module.
References: The References section is where a list of relevant and useful

textbooks, journals, articles, electronic contents or sources can be found. The list
can appear in a few locations such as in the Course Guide (at the References
section), at the end of every topic or at the back of the module. You are
encouraged to read or refer to the suggested sources to obtain the additional
information needed and to enhance your overall understanding of the course.
ASSESSMENT METHOD
Please refer to myINSPIRE for the latest assessment method.
REFERENCES
David, F. R. (2003). Strategic management: Concepts and cases (9th ed.). New
Jersey: Prentice Hall.
Ellis, J. R., & Hartley, C. L. (2006). Managing and coordinating nursing care
(4th ed.). Philadelphia: Lippincott William & Wilkins.
Falco, J., Wenzel, K., Quimby, D., & Penny, P. (2000). Moving differentiated
practice from concept to reality. Aspen Advisor for Nurse Executives,
15(5) 6 9.
Hood, L. J., & Leddy, S. K. (2006). Leddy & PepperÊs conceptual bases of
Professional Nursing (4th ed.). USA: Lippincott William & Wilkins.
Huber, D. (2000). Leadership and nursing care management (2nd Ed.)

Philadelphia: WB Saunders.
Jones, R. A. P., & Beck, S. E. (1996). Decision making in nursing. Clifton Park, NY:
Delmar Learning.
Kelly, H. (2003). Nursing leadership and management. Canada: Thomson.
Marquis, B. L., & Huston, C. J. (2006). Leadership roles and managment functions
in nursing theory and application (5th ed.). USA: Lippincott William &
Wilkins.

xiv COURSE GUIDE
Nelson, J. W. (2000). Consider this models of nursing care: A century of

vacillation. Journal of Nursing Administration, 30(4), 156, 184.
Reed, C. R., & Pettigrew, A. C. (1999). Self management: Stress and time. St Louis:
MO: Mosby.
Shullanberger, G. (2000). Nurse staffing decisions: An integrative review of the

literature. Nursing Economics, 18(3), 124 136.
Tappen, R. M. (2001). Nursing leadership and management: Concept and

practice. Philadelphia: F.A. Davis.
Yoder, P. S. (2003). Leading and managing in nursing (3rd ed.). USA: Mosby.
TAN SRI DR ABDULLAH SANUSI (TSDAS)

DIGITAL LIBRARY
The TSDAS Digital Library has a wide range of print and online resources for the
use of its learners. This comprehensive digital library, which is accessible through
the OUM portal, provides access to more than 30 online databases comprising
e-journals, e-theses, e-books and more. Examples of databases available are
EBSCOhost, ProQuest, SpringerLink, Books24x7, InfoSci Books, Emerald
Management Plus and Ebrary Electronic Books. As an OUM learner, you are
encouraged to make full use of the resources available through this library

Topic Introduction to
Management
1 in Nursing
LEARNING OUTCOMES
By the end of this topic, you should be able to:
1. Distinguish between management and leadership in nursing;
2. Discuss the principles and processes of management: planning,
organising, staffing, directing and controlling;
3. Describe strategic planning and SWOT analysis; and
4. Explain the management theories in relation to nursing.
INTRODUCTION
Managers are people who do things right and leaders are people who do the
right things.
(Bennis & Nanus, 1985)
Which one do you prefer to be? It is difficult to distinguish between leadership

and management because the terms are interchangeable. A leader is someone
who has influence over others. Effective leaders view things globally, create
visions of what might be, inspire others, do not fear taking risks and are able to
work with others in more connected ways. On the other hand, managers receive
their title because of their position in the organisation. Managers tend to focus
their energy and effort on ensuring a smooth workflow. All professional nurses
are leaders because they influence others.

2 TOPIC 1 INTRODUCTION TO MANAGEMENT IN NURSING
Is there a difference between leadership and management? Yes, there is. The term
management implies supervision, control or direction of the unit or group of
employees. Managers plan, organise and coordinate, often directing individual
efforts towards the achievement of a common goal. A manager is in a position of
leadership, but he or she may not have leadership qualities.
Managers may have organisational skills, whereas leaders have personality and
charisma. StepPhen Covey stated in his book „The 7 Habits of Highly Effective
People‰:
„Management is efficiency in climbing the ladder of success; leadership

determines whether the ladder is leaning against the right wall.‰
Imagine you are in a supervisory role as a head nurse or a team leader. A

manager definitely needs well-developed management skills to run and organise
a unit or department efficiently. Leadership qualities can enhance your ability to
manage successfully.
So, is it desirable to have both management and leadership skills? Going back to
Stephen CoveyÊs ladder, both skills are important to demonstrate to your staff
that the ladder you have to put out for them to climb will lead to success because
the position where it has been placed makes sense; for example, a supportive and
healthy environment. Let us now proceed to explore the management process,
strategic planning and management theories.
1.1 PROCESS OF MANAGEMENT

If you are practising the nursing process in your clinical practice, it will provide
you with a clearer picture as the management process is similar to the nursing
process.

TOPIC 1 INTRODUCTION TO MANAGEMENT IN NURSING 3
Figure 1.1: Meaning and principles of management
1.1.1 Planning
„The greatest thing in the world is not so much where we are, but in what
direction we are moving.‰
Oliver Wendell Homes.
Nurses have the opportunity to make a difference by planning new strategies for
the future and by influencing the direction of healthcare. Planning encompasses
forecasting, establishing objectives, devising strategies, developing policies and
setting goals.
The process of planning must involve managers and employers throughout the
organisation. The important point is that all managers do planning and should
involve subordinates in the process in order to facilitate employee understanding
and commitment.
Planning can have a positive impact on organisational and individual

performance. Planning allows an organisation to identify and take advantage of
external opportunities as well as minimise the impact of external threats.
Planning is more than extrapolating from the past and present into the future.
A manager of an organisation is usually familiar with the term „strategic

planning‰. It is very important for you to know about it. Figure 1.2 explains the
steps in strategic planning.

Figure 1.2: Key steps in strategic planning
So, what is strategic planning?
Strategic planning is selecting and organising the institution in order to keep it

healthy. An organisation can employ a strategic planning process to establish a
long-range plan or budget; deciding on the direction that the organisation should
take over the next 3, 5 or 10 years.
One of the outcomes from a long-range plan is the decision to prepare specific
programme budgets. Programme budgets are used primarily to evaluate new
programmes being considered to help the organisation attain its long-range plan.
The process involves an external assessment to examine opportunities and

potential threats and an internal assessment to identify its strengths and

weaknesses.
The strategic management process is critical to the organisationÊs success.

Managers and their staff must not only do the things they do well but must also
carefully decide on what must be done.
The process of planning must involve managers and employees throughout an

organisation. The important point is that all managers do planning and should
involve subordinates in the process to facilitate employee understanding and
commitment.
Planning can have a positive impact on organisational and individual

performance. Planning allows an organisation to identify and take advantage of
external opportunities as well as minimise the impact of external threats.
Planning is more than extrapolating from the past and present, into the future.
There are two major types of organisational planning: long-range, or strategic

planning, and short range, or operational planning. One planning text quotes
Henry Thoreau, „It is not enough to be busy – the question is, what are we busy
about?‰ This simple question should cause nurse managers to pause and
consider their role in the budget process. As managers are always busy because
of daily routine workload, they have little time to plan for the future or to
introduce innovations.
Nurse managers are more likely to be involved in the operational planning,

which is done in conjunction with budgeting, usually a few months before the
new fiscal year. It develops the departmental maintenance and improvement
goals for the coming year.
Strategic Planning Process

It is important that top management be committed to strategic planning.
Managers need to be taught the importance of strategic planning and the way to
do it. The process, which gives planners a sense of direction, should involve
many people.
A situation audit, or environmental assessment should be done to analyse the

past, current and future forces that affect the organisation.
A SWOT (Strengths, Weaknesses, Opportunities, Threats) analysis worksheet is

helpful. Each quadrant of a paper is labeled as one of the four categories, and
appropriate factors are listed in each quadrant for a bird's eye view of the
situational audit. Refer to Figure 1.3 for a SWOT analysis.

Strength: Opportunities:
Management development Nurse recruitment
Qualifications of staff Physician recruitment
Medical staff expertise Referral patterns
Facilities New programmes
Location New markets
Quality of service Diversification
Population growth
Improved technology
New facilities
Weakness: Threats:
Scarcity of staff Shortage of nurses
Financial situation Decrease in patient satisfaction
Cash flow position Increase in accounts receivable
Marketing efforts Decrease in demands for services
Marketing share Competition
Regulations
Litigation
Unionisation
Loss of accreditation
Figure 1.3: SWOT Analysis
After the situation audit is done, the management team reviews the philosophy,
identifies vision and values , writes a purpose or mission statement, identifies
organisational goals and objectives, plans strategies to accomplish the objectives,
identifies required resources and determines priorities and accountability while
setting the time frames (Huber, 2006, Roussel, Swansburg & Swansburg, 2006;
Sullivan & Decker, 2005; Yoder Wise, 2007).
ACTIVITY 1.1
Suppose you are the manager of a unit and intend to change the patient
care management system from task-oriented to patient-centred care.
How you will plan this? Discuss.
The website below provides an excellent narrative on the „Benefits of Strategic

Planning,‰ „Pitfalls of Strategic Planning,‰ and the „Steps in Doing Strategic
Planning.‰
http://www.entarga.com/stratplan/index.htm

1.1.2 Organising
Organising is defined as establishing the structure to carry out plans,
determining the most appropriate type of patient care delivery and grouping
activities to meet the unit goals. Other functions involve working within the
structure of the organisation and understanding how to use power and authority
appropriately.
Organising means determining who does what and who reports to whom. The
organising function of management can be viewed as consisting of three
sequential activities: breaking tasks into jobs (work specialisation), combining
jobs to form department (departmentalisation) and delegating authority.
Departmentalisation results from limitations on the effective span of

management, division of work and the need for cooperation. Its primary purpose
is to sub-divide the organisational structure so that managers can specialise
within limited ranges of activity. Delegating authority is an important activity, as
evidenced in the old saying „You can tell how good a manager is by observing
how his or her department functions when he or she isnÊt there‰.
In Wealth of Nations, published in 1776, Adam Smith cited the advantages of

work specialisation in the manufacture of pins:
One man draws the wire, another straightens it, a third cuts it, a fourth points it,
a fifth grinds it at the top for receiving the head. Ten men working in this manner
can produce 48,0000 pins in a single day, but if they had all wrought separately
and independently, each might at best produce twenty pins in a day.
1.1.3 Staffing
ACTIVITY 1.2
What do you think about Malaysian nurses who have migrated to other
countries? Have you decided your career pathway after you have
completed this course? Share your thoughts with your coursemates.
Nurses are the main source of care for patients during the most vulnerable times
in their lives, so a shortage of nurses poses a serious risk. Turnover of staff is
expensive and it is costly to recruit, orient and train new nurses.

The management function of staffing, also referred to as human resource

management activities is shown in Figure 1.3.
Figure 1.3: The human resource management activities
Let us now discuss about turnover; is it related to staffing?
Turnover is the rate at which employees leave their jobs for reasons other than
death or retirement. Turnover is expensive because of the resulting recruitment
and orientation costs of hiring new staff to fill the vacancies. Malaysia needs
another 100,000 nurses to fulfill the nurse-patient ratio of 1:200 population.
Therefore we need to produce 8000 nurses annually in order to meet the
requirement and the attrition rate remains high every year as nurses migrate to
other countries for better salaries.
The shortage of nurses is a current issue not only in Malaysia

but also worldwide.

So, how to plan for staffing in response to these shortages? To answer this
question, we take a look at Table 1.1 which explains the two aspects, namely:
• Leadership roles; and
• Management functions associated with preliminary staffing functions.
Table 1.1: Leadership Roles and Management Functions
Leadership Roles Management Functions
• Plans for present and future staffing • Ensures that there is an adequate
needs by adopting a proactive skilled workforce to meet the goals of
approach to knowledge of current and the organisation.
past staffing events.
• Shares responsibility for the
• Identifies and recruits talented people recruitment of staff with organisation
to the organisation based on their recruiters.
performance and competency levels.
• Plans and structures appropriate
• Seeks diversity in staffing, from interview activities.
different backgrounds, working
• Uses techniques that increase the
experiences and knowledge which
validity and reliability of the interview
reflect the diversity of the population
process.
being served.
• Applies knowledge of the legal
• Is self-aware of personal biasness
requirements of interviewing and
during the pre-employment process.
selection to ensure that the organisation
• Seeks to find the best possible fit is not unfair in its hiring practices.
between employeeÊs unique talents and
• Develops established criteria for
organisational staffing needs.
selection.
• Periodically reviews induction and
• Uses knowledge of organisational
orientation programmes to ascertain
needs and employee strengths to make
they are meeting unit needs.
placement decisions.
• Ensures that each new employee
• Interprets information in the employee
understands appropriate organisational
handbook and provides input for
policies.
handbook revisions.
• Continually aspires to create a work
• Participates actively in employee
environment that promotes retention
orientation, continuous nursing
and worker satisfaction.
education and research activities.

1.1.4 Directing
Directing includes several staffing functions. Directing entails human resource
management responsibilities such as motivating, managing conflict, counselling,
delegating, communicating and facilitating collaboration. Nurses should be
equipped with communication skills in order to provide correct information on
what the patient needs to know, so that the patient can make decisions, reduce
his/her anxiety and feel safe and secure. Counselling is important in helping
patients share their problems with nurses.
Delegation is defined as transferring authority to a competent individual to

perform a selected nursing task in selected situations. The effective nurse
manager should be able to empower the subordinate to perform the task as well
as to monitor the process and outcome.
However, some common errors in delegation might happen, such as:

• Failure to delegate;
• Failure to release control;
• Inadequate or unclear direction/miscommunication;
• Lack of follow-up or supervision;
• Incompetent personnel; or
• Inadequate authority (empowerment).
Many things interfere with our ability to delegate. One may be our need for
control. Inability to delegate may be as a result of feeling, „If I want it done
correctly, IÊd better do it myself‰.
1.1.5 Controlling
Control is defined as an attempt to ensure that actual results come as closely to
planned results as possible. All managers in an organisation have controlling
responsibilities, such as conducting performance evaluations and taking
necessary action to minimise inefficiencies. Controlling consists of four basic
steps (see Figure 1.4).

Figure 1.4: Four steps in controlling responsibilities
For example, at the end of the year you will be evaluated by your manager based
on your job performance. He/she will highlight your achievements while giving
a little guidance for career development.
ACTIVITY 1.3
You have a problem of shortage of staff in your ward. As a nurse

manager how would you apply the concept of management process to
solve the problem?
ACTIVITY 1.4
An adverse effect is one of the risk management components, which is

important in nursing. You are required to look for the other
components and discuss in a small group. Present the outcome of your
discussion to the class.

1.2 MANAGEMENT THEORIES

Do you know that the current theories of management practice have evolved
from earlier theories? Most of our current understanding of management is based
on the classical perspectives of management that were introduced in the 1800s
during the industrial age as factories developed.
The classical perspectives include three sub-fields of management which are

scientific management (see Figure 1.5), bureaucratic theory (see Figure 1.6) and
administrative principles (see Figure 1.7) (Wren, 1979, Daft & Marcic, 2001).
Figure 1.5: Scientific management

Figure 1.6: Bureaucratic theory

Figure 1.7: Administrative theory

Figure 1.8: Organisational behaviour
For detailed explanation on management theories, please refer to Table 1.2.
Table 1.2: The Management Theories
MANAGEMENT
DESCRIPTIONS
THEORY
Scientific Management Productivity is the area of focus in this theory. It can be

achieved by preparing staff with adequate skills and
knowledge and using advanced equipment to increase
efficiency.
For example, in the Intensive Care Unit, all nurses should
be well-trained while cutting edge equipment should be
used to provide maximum care for patients.
Bureaucratic Theory In this theory, Weber believed efficiency is achieved

through impersonal relations within a formal structure,
for example from matron-sister-staff nurse. Competence
was the basis for hiring and promoting an employee.
Decisions were made in an orderly and rational way
based on rules and regulations. The bureaucratic
organisation is a hierarchy with clear superior–
subordinate communication and relations. It is based on
positional authority whereby an order coming from
someone at the top, such as the matron, is transmitted
through the organisation via a clear chain of command.

Administrative Principles This theory focuses on general principles of management,

for example the management process of planning,
organising, directing, coordinating and controlling.
Another aspect of this theory attributed by Barnard
emphasised on the concept of the informal organisation.
Barnard believed the informal organisation consists of
naturally forming social groups that can become strong,
powerful contributors to an organisation. This theory also
identified people as having free will and choosing to
comply with orders provided to them.
Organisational Behaviour This theory focused on the effect individuals have on the
success or failure of an organisation. The main concerns of
the human relations movement are individuals, group
process, interpersonal relations, leadership and
communication. Instead of concentrating on the
organisationÊs structure, nurse managers encourage staff
to develop their potential and help them meet their need
for recognition, accomplishment and a sense of belonging.
• The management process is similar to the nursing process. Both processes are
cyclical and may occur simultaneously.
• Management functions include:

(a) Planning;
(b) Organising;
(c) Staffing;
(d) Directing; and
(e) Controlling.
• Not only would the nurse manager be performing all phases of the
management process but each function has a planning, implementing and
control phase.

Administrative principles Bureaucratic organisation

Autocratic leadership Management process
1. Which of the following statements is true regarding the Bureaucratic

Theory?
(a) Efficiency is achieved through impersonal relations within a formal
structure.
(b) Efficiency is achieved by preparing staff with adequate skills and
knowledge and using advanced equipment to improve efficiency.
(c) The theory is focused on the effect individuals have on the success or
failure of an organisation.
(d) Informal organisations consist of naturally forming social groups that
can become strong and powerful contributors to an organisation.
1. Bureaucratic theory is one of the management theories. Discuss the

advantages and disadvantages of this theory in relation to nursing practice.
David, F. R. (2003). Strategic management, concepts & cases (9th ed.). New
Hood, L. J., & Leddy, S. K. (2006). Conceptual bases of professional nursing

(6th ed.). California, USA: Lippincott William & Wilkins.
Kelly-Heidenthal, P. (2003). Nursing leadership & management. Canada:

Thomson.

Marquis, B. L., & Huston, C. J. (2006). Leadership roles and management

functions in nursing, theory and application (5th ed.). California, USA:
Lippincott Williams & Wilkins.
Yoder-Wise, P. (2003). Leading and managing in nursing (6th ed.). California:

Lippincott William & Wilkins.

Topic Leadership and
Motivation
2
LEARNING OUTCOMES
1. Describe the different types of leadership styles;
2. Discuss motivation theories; and
3. Describe the role and responsibilities of a nurse as a team leader and
team member in a ward or clinic.
INTRODUCTION
Leadership comes from the inspiration for desired responses and getting work
done through others. Leaders focus on purpose and doing the right thing. They
are future-oriented, challenged by change, able to plan strategies and facilitate
human potential. Leaders need to use their knowledge of power and politics to
motivate people to act and to manage conflict. Knowledge of leadership theories
help leaders adjust their leadership styles to fit different situations (Marriner
Tomey, 2009).
Leadership is often thought of as more inspirational or guidance-oriented as well

as informal. Leaders have followers and supporters and can influence others
through a formal structure or by informal relationship. A leader does not
necessarily have to be a manager. Leadership relies more on personality traits
and people skills. These skills definitely can be developed by gaining experience,
having a mentor or attending classes.
The job of a nursing leader whether in service or in education is to get things

done through his/her employees or staff. In other words, the leader should be
able to motivate them to do their jobs well. Why do we need to motivate the
employees? The answer is survival. Motivated employees are more productive

20 TOPIC 2 LEADERSHIP AND MOTIVATION
and more creative. To be effective, leaders need to understand what motivates

employees within the context of the roles they perform.
However, motivating employees is easier said than done! Despite the abundance
of research and theories on motivation, the subject of motivation is not clearly
understood and in many instances, poorly practised. It has been suggested that
in order to understand motivation you need to understand the whole of human
nature. Obviously, this would be problematic as human nature or human
behaviour can be very simple and yet very complex too.
Surely, you know the old saying that you can take a horse to water but you
cannot force it to drink, unless of course it is thirsty. Similarly with people, they
will do what they want to do if they are motivated. In this module, you will
explore leadership styles and motivation theories and relate them with your
experiences.
2.1 INTERPRETATION OF LEADERSHIP

A leader is a person who leads a group of people to achieve certain objectives
which might have been agreed by the followers but set by the leader or as in a
democratic organisation, they have been derived through discussions and
deliberations by all members including the leader.
A leader plays a major role in ensuring that the group objectives are realised. In
every group even though no leader is appointed, a leader would appear among
them naturally. In a battle, if the leader is killed, the second person in command
will automatically take over the leadership. But in situations where all the leaders
of the platoon have died, the person who provided some ideas and suggestions
for their survival and well-being would usually be accepted by the platoon as
their natural leader. This person assumes leadership indirectly not by choice but
more so for the sake of his and his friendsÊ well-being and their survival will rise
above others in the group.
Leadership studies from the 1930s by Kurt Lewin and colleagues at the Iowa
State University conveyed information about three leadership styles that are still
widely recognised today. The three styles are autocratic, democratic, and laissez-
faire leadership.
Autocratic, Democratic and Laissez-faire Leadership

Autocratic leadership involves centralised decision making, with the leader
making the decisions and using power to command and control others. The
autocratic style is used by the leader in situations in which (1) the task outcome is
relatively simple (e.g., telling the nursing student to take the patientÊs
TOPIC 2 LEADERSHIP AND MOTIVATION 21
temperature); (2) most team members would agree with the decision and provide
consensus; and (3) a decision has to be made promptly.
Democratic leadership is participatory, with authority often delegated to others.

To be influential, the democratic leader uses expert power and the power base
afforded by having close, personal relationships. In the democratic style, the
leader will ask the opinions of the entire team, but the final decision usually lies
with the leader, or there may be mutual decision making by both team members
and the leader, with everyone having an equal vote. This process encourages
everyone to fully accept the teamÊs decision. This mutual style may be the most
creative because all have the opportunity to provide input and different
perspectives into the decision.
The third style, laissez-faire leadership, is passive and permissive and the leader
often defers decision-making.
Lewin (1938) contrasted these three styles and concluded that autocratic leaders
were associated with high-performing groups but that close supervision was
necessary and feelings of hostility were often present. Low productivity and
feelings of frustration were associated with laissez-faire leaders.
Ex-President of the National Union of Journalists Norila Mohd Daud once said:

ACTIVITY 2.1
Before we embark further into the content, who, in your opinion, has
the characteristics of a good leader in our country or in your
organisation? Discuss what makes that person a good leader.
Now, let us discuss leadership in relation to nursing practice.
Throughout your experience in the nursing profession, can you identify someone
with the characteristics of a good leader? Nurse leadership is vital. Nurses
depend on their leaders to set goals for the future and the pace for achieving
them. The leader, not the manager, inspires others to work at their highest level.
The presence of strong leadership sets the tone for achievement in the work
environment.
As Yuki (1998) states, leadership is a process of influence in which the leader

influences others towards goal achievement. Influence is an instrumental part of
leadership – inspiring and engaging others to participate.
NursesÊ satisfaction within the workplace is an important construct in nursing

and healthcare administration (see Figure 2.1). If nurses are not satisfied with the
working environment, they are less likely to work at the highest level and are
more likely to leave the organisation and go elsewhere (Stamps, 1997).
Figure 2.1: Recognition by the organisation motivates staff

Perhaps, you should spend a minute to think about this statement:
ACTIVITY 2.2
Do you think a leader should help others grow as professional nurses?

Discuss.
2.1.1 Key Concept

Nurses are leaders who make a difference to health care organisations through
their contributions of expert knowledge and leadership. Leadership development
is therefore a necessary component in a nurseÊs preparation as a healthcare
provider.
Leadership is a process of influence that involves the leader, the follower and
their interaction. Followers can be individuals, groups of people, communities
and members of the society in general.
Leadership can be formal and informal, occurring by virtue of being in a position

of authority in an organisation, such as a manager, or outside the scope of a
formal role, such as a member of a group.
Leadership and management are two different things. Management is viewed as

actions employed to cope with changes, while leadership is the effort to envision
and inspire change.

Can the leader effectively modify his or her behaviour and that of others?
(a) Traditional View

Leader is in the position of authority, exerting command and control, using
power over subordinates.
As professionals, nurses function as leaders when they influence others
towards goal achievement.
(b) Formal Leadership

A person is in the position of authority or in an assigned role within an
organisation that connotes influence, such as a Head Nurse or a Nurse
Manager.
(c) Informal Leadership

A person is considered to have emerged as a leader when he/she is
accepted by others and is perceived to have influence.
2.1.2 Leaders’ Characteristics

There are three characteristics of a leader as explained below:
(a) Guiding Vision

Focuses on a professional and purposeful vision that provides direction
towards the preferred future.
(b) Passion
Ability to aspire and align people towards lifeÊs goals.
(c) Integrity
Self-honesty and maturity. These will develop through experiences and
growth.
2.1.3 Transformational Leadership Competencies

Effective leadership requires the leader to display confidence and competence in
working with and through other persons. Some people may appear to be natural
born leaders, whereas others have to learn to develop leadership qualities and
skills.

Gurka (1995, p. 170) has identified three qualities of the transformational leader:
(a) Individual Consideration

Individual consideration is exhibited by promoting the growth of others,
recognising and supporting othersÊ needs and feelings and giving positive
feedback and recognition.
(b) Charisma
Charisma is exhibited by inspiring and motivating, demonstrating
enthusiasm and communicating in a positive manner.
(c) Intellectual Stimulation

Intellectual stimulation can be exhibited by creating a questioning
environment, acting as a mentor and challenging others to grow and learn.
Let us consider the following descriptions of effective leaders by Stephen R. Covey:
CoveyÊs Eight Habits of the Effective Leader (Adapted for Nurses)
(a) Be Proactive
Nurses need to set goals and work to achieve them. They accept their own
ability to be „response-able‰ in dealing with clientsÊ whole human
responses to their health concerns. They believe that „itÊs not what happens
to us, but our response to what happens to us that hurts us,‰ (Covey, 1989.
p73).
(b) Begin with the End in Mind

The nurse should identify what is really important and try to do what really
matters the most every day. „Management is efficiency in climbing the
ladder of success; leadership determines whether the ladder is leaning
against the right wall,‰ (Covey, 1989 p101).
(c) Put First Things First

The formula for the nurse who wants to stay focused on the important
business of nursing and give less energy to the unimportant is to set
priorities, organise and finally perform. The challenge for nurses is to
manage time in such a way that most of it is used for urgent important
projects such as health promotion/illness prevention (Covey, 1989).

(d) Think Win-Win or No Deal

Interdependence is the most mature goal for any relationship; for example,
a client benefits from being empowered by a professional nurse providing
informational support, and the nurse benefits by having the interventions
validated and the sense of presence with the client valued (Covey, 1989).
(e) Seek First to Understand, then to be Understood

Empathy is the habit reflected in this principle. The ability to focus on the
clientÊs reality to experiences is vital to positive communication (Covey,
1989).
(f) Value Differences and Bring All Perspectives Together

Respect is the characteristic that enables a nurse to develop this habit. To
the extent that the nurse facilitates respect for his/her perspectives, the
client is likely to feel freer to seek possible alternatives (Covey, 1989).
(g) Have a Balanced, Systematic Programme for Self-Renewal

Consistency in having a regularly planned and balanced programme for
renewal to prevent weakening of the body, mechanisation of the mind,
exposure of raw emotions, and desensitisation of the spirit. Nursing
leadership ability is enhanced if they consistently participate in activities
that renew the four aspects of self: physical, mental, emotional-social and
moral being (Covey, 1989).
(h) Find Your Own Voice and Inspire Others to Find Theirs
Being truly authentic towards oneÊs personal life mission and helping
others find themselves; foster the development of new leaders and promote
deep satisfaction with life and work.
ACTIVITY 2.3
Discuss the following with your coursemates:

1. Based on your understanding so far, what is the difference between
leadership and management? How do you distinguish between the
two?
2. Identify one leadership characteristic which is suitable in your
nursing practice.
3. Can the eight habits of the effective leader by Covey be
implemented in our nursing practice?

2.1.4 Developing the Role of a Leader

Now, let us begin this section by discussing leadership development tasks
(see Figure 2.2).
Figure 2.2: The leadership development tasks
(a) Select a Mentor

A mentor is someone who models behaviour, offers advice and criticism,
and coaches the novice to develop a personal leadership style. If you want
to be a mentor you should have the qualities of a teacher, resource person,
stimulator and provider of experience in day-to-day care practice
(Earnshaw, 1995).
Where do you find a mentor?
Usually, a mentor is someone who has experience and some success in the
leadership realm of interest, such as in a clinical setting or in an
organisation. The mentor must agree to work with the novice leader and
must have some interest in the noviceÊs future development.
(b) Lead by Example

An effective leader knows that the most effective and visible way to
influence people is to lead by example. Desired behaviour can be modeled.
If the goal is to have improved relationships amongst the followers, the

leader must exhibit respect and patience with followers. Great leaders
create civilised work environments (Kerfoot, 1999).
The effective leader does not send members to do a job, but rather leads
them toward a mutual goal as a team.
(c) Accept Responsibility/Accountability/Empowerment

A leader sometimes reacts in strange ways when negative outcomes occur.
Sometimes the leader seeks to blame others or makes excuses for
undesirable or unintended outcomes. In accepting responsibility, the leader
needs to know that there is reward in victory and growth in failure.
We should remember!
No one plans to fail but an effective leader sees failure as an opportunity to
learn and grow so that previous failures are never repeated.
People who cannot accept any personal responsibility and become
demoralised by their perfectionist attitude toward life when failure occurs
will not progress as leaders (Kerfoot, 1998).
(d) Share the Rewards

An effective leader is as eager to share the glory as to receive it. The more
respect and trust are shared with others, the more they are returned to the
leader.
Followers who think the leader is working to make them look good will
follow eagerly. Followers form a network and a support base for the leader.
(e) Have a Clear Vision

Leaders see beyond where they are and see where they are going. Strong
leaders are proactive and futuristic. The effective leader knows why the
journey is necessary and takes the time and energy to inspire others to go
along.
Effective leaders share their vision and empower followers to come along to
achieve it. They also share their leadership skills and successes towards the
achievement of a goal.
(f) Be Willing to Grow

Complacency leads to stagnation. Leaders must continually read about new
ideas and approaches, experiment with new concepts and capitalise on a
changing world. Continued education contributes to self-confidence by
contributing to skills and knowledge needed for success (Allen, 1998).
Setting goals that complement the vision will help the aspiring leader know
where to invest time and energy to grow into the desired role.

2.1.5 The Nurse as a Leader

(a) The Staff Nurse as Leader
Nurses who believe that they have good ideas for future improvements
should volunteer for opportunities to lead. Developing leadership skills for
staff nurses can happen in several ways. Besides volunteering for
leadership roles within the workplace, professional involvement with
organisations outside of the workplace can help in the development of
leadership skills (Kerfoot, 1999).
It is important to remember⁄
Leadership can be developed and that staff nurse leaders can help establish
workplaces that are satisfying and rewarding.
(b) The Nurse Manager as Leader

Management and leadership can be a strong combination of success. The
nurse manager ensures that the day-to-day elements of the workplace are
done correctly. In the role of a leader, the manager raises the level of
expectations and helps employees reach their highest level of potential
excellence. The primary role of the leader is to inspire (Atchison, 1990).
An essential element of success for the nurse manager as a leader is the
inclusion of staff nurses in decision-making. The nurse manager inspires
staff by involving them in changing the workplace to make it more
satisfying. In so doing, the nurse manager also develops personal
leadership skills.
Tips for Becoming a Leader

(a) Take advantage of leadership opportunities to practise your leadership skills.
(b) Every leader has made mistakes. The truly inspired leaders have learned
from them and moved forward.
(c) Get some help – a caring mentor is the best way to develop leadership
ability. The mentor can give you the benefit of experience and will serve as
a resource to get feedback on actions and exploring options.
The topic can be assessed through the website:

http://www.mosby.com/MERLIN/Yoder-Wise
Health Leadership Associates:

http:/www.leadershipdirectories.com

ACTIVITY 2.4
Share your thoughts on the following questions with your coursemates.

1. Are some people born to be leaders, or can leadership be taught and
learned?
2. How can leaders keep themselves from „burning out‰?
3. Is there one best way to lead?
2.2 WHAT IS MOTIVATION?

Motivation can be defined as „that which provides motive‰ and motive as
„something that prompts a person to act in a certain way, or determine volition;
incentive.‰ (Webster's Dictionary).
Motivation is not explicitly demonstrated by people but rather interpreted from

their behaviour. Motivation is able to influence our choices, create direction,
intensity and persistence in our behaviour (Hughes, Ginnett & Curphy, 1999).
Motivation is a difficult concept to analyse because many different factors

influence that which gets your behaviour started and more importantly keeps it
going.
Motivation is important because it affects your arousal level (the intensity or

enthusiasm with which you will pursue something), choice (of which you will
put into your work), performance level (the amount of effort you will put into
your work) and persistence (whether you will continue working despite
resistance or just give up). Motivation affects your emotional state in determining
whether you derive positive experiences and satisfaction such as when most of
your students are able to solve the problems given.
If you are interested in creating change, influencing others and managing

performance and outcomes, you should be able to understand the motivation
that it is reflected on a personÊs behaviour.
Motivation is a process that occurs internally to influence and direct our

behaviour in order to satisfy needs (Lussier, 1999).

2.2.1 Motivation Theories

Motivational theories sound so „textbookish‰. Is it really applicable to the day-to-
day operations of a nursing unit?
Yes. Motivation theories are useful because they help explain why people act the
way they do and how managers can relate to individuals as human beings and
workers. Understanding these theories help us to develop better practices and
gain a better understanding of the people around us.
When you are interested in creating change, influencing others and managing
performance and outcomes, it is useful to understand the motivation that is
reflected on the personÊs behaviour.
Selected Motivation Theories
Frederick Herzberg (1923–2000): Two-factor Theory
Hygiene-maintenance factors such as working conditions,

salary, status and security, motivate workers by meeting
safety and security needs and avoiding job dissatisfaction.
Motivator factors such as achievement, recognition and the

satisfaction of the work itself, promote job enrichment by
creating job satisfaction.
To get information on motivation related to productivity you can refer to Anne

Bruce's book How to Motivate Every Employee: 24 Proven Tactics to Spark
Productivity in the Workplace published by McGraw-Hill in 2003.

Douglas McGregor (1906–1964): Theory X
Leaders must direct and control as motivation results from

reward and punishment. Theory X leads naturally to an
emphasis on the tactics of control-procedure and techniques
for telling people what to do; for determining whether they
are doing it; and administering rewards and punishment.
Theory X explains the consequences of a particular
managerial strategy. Because its assumptions are so
unnecessarily limiting, it prevents managers from seeing the
possibilities inherent in other managerial strategies. As long
as the assumptions of Theory X influence managerial
strategy, organisations will fail to discover, let alone utilise, the potentialities of
average human beings.
Theory Y:
Theory YÊs purpose is to encourage integration, to create a situation in which an
employee can achieve his or her own goals best by directing his or her efforts
towards the objectives of the organisation. It is a deliberate attempt to link
improvement in managerial competence with the satisfaction of higher-level ego
and self-actualisation needs. Theory Y leads to a preoccupation with the nature
of relationships, with the creation of an environment which will encourage
commitment to organisational objectives and which will provide opportunities
for the maximum exercise of initiative, ingenuity, and self-direction in achieving
them.
Leaders remove obstacles as workers have self-control and self-discipline; their

reward is their involvement in work.
William Ouchi (1943– ): Theory Z
Collective decision-making, long-term employment,

mentoring, holistic concern and use of quality circles to
manage service and quality; a humanistic style of motivation
based on Japanese organisations.

Abraham Maslow (1908–1970)

Abraham Maslow, a developmental psychologist, described the human hierarchy
of needs and commented on how work helps to meet those needs. Work helps to
meet safety and security needs by providing pay, which can help to provide
food, shelter and clothing. Once the lower needs are met, Maslow believed that
humans would strive for self-esteem and then self-actualisation.
In thinking about motivation from a management perspective, it is very

important to appreciate this point:
You cannot motivate people; you can only

influence what theyÊre motivated to do.
Figure 2.3 below applies MaslowÊs hierarchy of human needs to how

organisations motivate employees. When this theory is applied to staff, leaders
should be aware that the need for safety and security, such as an adequate salary
and a comfortable working environment will override the opportunity to be
creative and inventive, such as in promoting a job change.

Hierarchy of human needs begins with physiological needs, then progressing to

safety, social, self-esteem and self-actualising needs. Lower-level needs will
always drive behaviour before higher-level needs are addressed.
Figure 2.3: How organisations motivate with the hierarchy of needs theory
Adapted from Kelly-Heidenthal P., 2003, Nursing Leadership &
Management, Canada, Thomson
• The role of the nurse leader is to share a vision and provide the means for the
followers to reach it.
• When the group succeeds, the leader succeeds.
• Various leadership opportunities are available; it is up to the nurse to take
advantage and contribute to the progress of the nursing profession.
• Key elements to becoming an effective leader can be learned and applied:
– Select an effective and willing mentor;
– Lead by example through role modeling;
– Share the rewards with the followers;
– Have a clear vision that followers can support; and/or
– Be willing to grow and change to meet current needs.

• There are many opportunities to lead in nursing. To thrive in the leadership

position, the nurse must do the following:
– Maintain balance;
– Generate self-motivation;
– Build self confidence;
– Listen to constituents; and
– Have a positive attitude.
Autocratic leadership Hawthorne effect

Formal leadership Leadership
1. Select the true combination.

(a) Scientific Management Theory – Max Weber
(b) Two-Factor Theory – Frederick Herzberg
(c) Theory X, Y and Z – Douglas McGregor
(d) Administrative Principles – Kelly Heidenthal
2. Which of the following characteristics describe an effective leader?

(i) Accepts responsibility
(ii) Shares the rewards
(iii) Has a clear vision for the future
(iv) Takes advantage of others
(a) i
(b) i, ii
(c) i, ii, iii
(d) iv

4. Which of the following is NOT a leaderÊs characteristic.

(a) Guiding Vision
(b) Passion
(c) Integrity
(d) Charisma
1. Describe the type of leader you want to be as a nurse in a health care

organisation. Identify specific behaviours you plan to use as a leader.
2. In what ways are the transformational leadership and charismatic

leadership theories useful to your development as a leader?
Covey, S. R. (1989). The 7 habits of highly effective people. New York: Simon &
Schuster.
Covey. S.R. (2004). The 8th habit: New York: Free Press.
David, F. R. (2003). Strategic management: Concepts & cases (9th ed.). New
Hood, L. J., & Leddy, S. K. (2006). Conceptual bases of professional nursing

(6th ed.). California, USA: Lippincott William & Wilkins.

functions in nursing, theory and application. California, USA: Lippincott
William & Wilkins.
Yoder P. S. (2003). Leading and managing in nursing (3rd ed.). USA: Mosby.

T op i c Managing the
Ward and
3 Clinical Area
LEARNING OUTCOMES
1. Discuss two types of patient classification system (PCS);
2. Distinguish between the two PCS and the new model;
3. Explain the four issues of staff scheduling.
INTRODUCTION
High quality nursing care should be the goal of every nurse, educator and
manager. High quality to me means care that is individualised to a particular
patient, administered humanely and competently, comprehensively and with
continuity. Primary nursing is one means of accomplishing that quality of
care.
Mary Manthey (1980)
Do you agree with the above statement? What is your definition of high quality
nursing? The ability of a nurse to provide safe and effective nursing care to a
patient is dependent on the knowledge, skills/competency level, attitude and
experience of the staff, the severity of illness of the patients, the amount of
nursing time available, the model of the care delivery system, care management
tools and organisational support. This topic will explore these factors, how they
affect planning for staffing and the results of staffing plans.

38 TOPIC 3 MANAGING WARD AND CLINICAL AREA
3.1 EFFECTIVE STAFFING

Nursing staffing began with a ratio of one nurse to many soldiers during the
Crimean War when Florence Nightingale began her noble cause.
Some Important Facts about Florence Nightingale:
Florence Nightingale (1820–1910), also known as

„The Lady with the Lamp‰ shown here, became
famous for her medical care of the sick and
wounded soldiers during the war. Not only did she
start the modern nursing profession, she also paved
the way for women to enter the medical profession.
Prior to that, women had been excluded from
medicine, and were confined to being midwives or
healers using traditional herbal medicine. Although
most nurses today are women, the situation was
different prior to Florence NightingaleÊs time.
Source: www.educonnect.com
Today, you may see the ratio of one nurse to one patient in a critical area. In
todayÊs rapidly changing health care environment, many variables must be
considered in determining staffing requirements. The effectiveness of the staffing
pattern is only as good as the planning that goes into its preparation.
3.1.1 Determination of Staffing Needs

No matter how effective an organisation performs in its effort to retain existing
staff, some turnover must be expected. Some staff will retire whilst others will be
stationed to different parts of the country. The most effective personnel strategy
in a healthcare organisation is to work at retaining the staff they already have.
Major efforts should be made in an attempt to reduce undesired turnover. One
key to staff retention is to have a high level of nurse satisfaction.
Surprisingly, very little is known about what leads to nurse satisfaction. Many
factors are believed to be relevant in keeping nursing staff satisfied. The issue of
financial payment is, of course, relevant. A higher salary at another institution
may cause staff to move from one organisation to another.
One key reason for the failure to retain nurses is burnout. Burnout is more likely
to cause nurses to leave the nursing fraternity completely. Nurses suffering from

TOPIC 3 MANAGING WARD AND CLINICAL AREA 39
burnout tend to be less productive, more error-prone, have low morale and
accrue a considerable number of sick days. However, the most obvious cause of
burnout is short-staffing. When there are simply not enough nurses to get the job
done on a given day or week, the existing staff may be required to take in the
extra workload and it is very common for staff in such instances to be required to
undertake double duty. The staff will be very tired at the end of the shift. The
other factors could be due to fewer opportunities for career development and
financial problems, leading nurses to leave the organisation and consequently
causing even greater stress on those that remain.
Let us think, what can be done to help reduce burnout?
Staff will be more contented if they believe they have a caring manager, who is
interested in their development. A manager should be supportive, fair and be
seen as using staff time wisely. The overall attitude and the support system of the
unit manager and administrators could, to some extent, offset the problems of
burnout.
Let us now discuss on the current shortage of nurses. The nurse-patient ratio in
Malaysia is 1:324 (2009) population. We would require another 100,000 nurses to
meet the ideal nurse-patient ratio of 1:205 (2015) in year 2015. The current
international registered nurse (RN) shortage is predicted to be worse in the
coming years. The Bureau of Labour Statistics projects that the need for RN will
rise by as much as 25% by 2005 and 36% by 2020.
The cost of coaching new staff is high. Increasing retention of existing employees
decreases the need for orientation. As you remain in the same position and feel
comfortable, you would begin to develop short term and long term professional
goals.
When you are satisfied with your working environment and job roles, you are
more likely to be motivated to commit to the organisation.
When you become a more experienced nurse, you will be required to coach new
staff, including them in decision making and helping them to become team
players. These will make a significant difference in the turnover rate. How an
individual is treated by the senior and also the superior, the perception of
fairness and a willingness to see each employee as an individual, contribute to
reducing staff turnover.

The following are some interesting statements regarding the nursing career:
(a) An Aging Nursing Workforce

The average age of nurses is 44 to 46 years. Baby Boomers (those born
between 1946 and 1964) will begin to retire by 2011. California predicts
that 50% of its nurses will no longer be practicing by 2012.
(b) Growing Demand

In a growing RN job market, the prediction is that by 2020, the demand
for RNs will rise by 36%.
3.1.2 Patient Classification System
ACTIVITY 3.1
Given above are two different scenarios of patients in a clinical ward.

Patient A just had a heart attack. But, his condition is already
stabilised. Patient B was involved in an accident. He has a broken leg.
If you are the Nurse Manager, how would you determine the
allocation of staff for each patient? What are the criteria that you would
consider when you are making this decision?

To identify how many staff are needed at any given time in the unit, it is
necessary to determine the patientÊs actual needs. A Patient Classification System
is a measurement tool used to articulate the nursing workload for a specific
patient over a period of time. This is also called patient acuity.
As a patient becomes more ill or sicker, the acuity level rises, meaning the patient
requires more nursing care. On the other hand, if a patientÊs acuity level
decreases, the patient requires less nursing care. The criteria reflecting the care
needed in bathing, mobilising, eating, supervision, assessment, and observations
are based on 14 activities of daily living (ADL) by Virginia Henderson.
The ideas are matched to the latest clinical technology and caregiver skills
variables (Malloch & Conivaloff, 1999). There are two different types of PCS (see
Figure 3.1):
Figure 3.1: Two types of patient classification system
(a) Factor System

The factor system uses units of measure that equate to nursing time. This
system attempts to capture the cognitive functions of assessment, planning,
intervention and evaluation of patient outcomes along with written
documentation processes. This system is the most popular type of
classification system because of its ability to project care needs for
individual patients as well as patient groups. The time assigned for
different nursing activities can be changed over time to reflect the changing
needs of the patients or hospital systems.

There are some advantages and disadvantages from the system, such as:
(i) Advantages
Data are readily available to managers and staff for day-to-day
operations. These data provide a base of information against which
one can justify changes in staffing requirements. For instance, using
the computer database where all the data has to be inserted in the
standard format.
(ii) Disadvantages
The ongoing workload for the nurse having to classify patients daily.
The system does not holistically capture the patientÊs needs for
psychosocial, environmental and health management support. When
a nurse is a novice, he/she may take longer to perform the activities
than the average or more experienced nurse.
(b) Prototype System

The prototype system allocates nursing time to a large patient group based
on similar patients known as diagnostic-related groups; for example, taking
care of the patient in the same discipline such as the endocrine or
cardiovascular unit. The model assumes that on average this will reflect the
standard routine nursing care provided.
(i) Advantages
The advantage of this system is the reduction of work for the nurse
because he/she is not required to classify the patient daily.
(ii) Disadvantages
No ongoing measure of the actual nursing work required by the
individual patient. There is also no ongoing data to monitor the
accuracy of the pre-assigned nursing requirements.

Let us refer to the following table of summary.
Table 2.1: Summary of Types of PCS and the Advantages / Disadvantages
Type of PCS Advantages Disadvantages
Factor System
• Uses units of measure • Readily available data • Becomes ongoing
that equate to nursing for managers and staff workload for the nurse
time. in their day-to-day in classifying patients
• Attempts to capture the operations. daily.
cognitive functions of • These data provide a • The system does not
assessment, planning, base of information capture the patientÊs
intervention and against which one can need for psychosocial,
evaluation of patient justify changes in environmental and
outcomes along with staffing requirements. health management
written documentation support.
processes. • A novice may take
• The most popular type longer to perform
of classification system. activities than the
• Able to project care average or more
needs for individual experienced nurse.
patients as well as
patient groups.
• The time assigned for
different nursing
activities can be
changed over time to
reflect the changing
needs of the patients or
hospital systems.
Prototype System
• Allocates nursing time • Reduces work for the • No ongoing measure of
to large patient group nurse because he/she is the actual nursing
based on similar not required to classify work required by
patients or known as the patient daily. individual patient.
diagnostic-related • No ongoing data to
groups monitor the accuracy of
• Assumes that on the pre-assigned
average this will reflect nursing requirements.
the standard routine
nursing care provided.

(c) New Model

Figure 3.2 shows the new model of PCS. These indicators are measured
during each shift by the staff as part of staff assessment. The model
attempts to move away from tasks to indices that measure the professional
components of nursing care and patient outcome (Malloch & Conivaloff,
1999).
Figure 3.2: PCS new model
3.2 SCHEDULING
Scheduling of staff is the responsibility of the ward Head Nurse or Manager.
He/she must ensure that the schedule places the appropriate staff on each day
and shift for safe and effective patient care. Some issues to consider as you
schedule your staff are shown in Figure 3.3.

Figure 3.3: Scheduling issues
Self-scheduling is a process in which staff in a unit collectively decide and

implement the monthly work schedule (Dearholt & Feathers, 1997). Self-
scheduling has been implemented to boost staff morale by increasing staff
control over their work environment through self-governance activities. It
provides opportunities for staff to increase communication among themselves
and promotes empowerment and professional growth. This form of scheduling
provides maximum flexibility for staff and serves to increase their sense of
ownership and shared responsibility in ensuring that their respective works are
adequately recognised (Shullanberger, 2000).
ACTIVITY 3.2
To ensure that patient care needs are met, there must be a structure to
the self-scheduling programme. In your opinion, what do you think of
self-scheduling and what would be the consequences if you want to
introduce this system in our local setting?
3.3 EVALUATION
Providing feedback to employees regarding their performance is one of the
strongest rewards an organisation can provide. Performance appraisals are
individual evaluations of work performance. Evaluations are usually done
annually but also may be required after a scheduled orientation period for a new
employee.

The actual appraisal is sometimes viewed as a negative experience. For example,

many Nurse Managers perceive appraisal as a time-consuming process of
endless paperwork. Emphasis should instead, be placed on role clarification,
evaluation of competency-based performance outcomes, and the employeeÊs
contributions to the organisation. Performance appraisals provide the basis for
many administrative decisions, including promotions, salary increases and
disciplinary actions.
Let us discuss evaluation based on competency and staff development. How do

you measure competency?
Ann Kobs, a consultant, clarifies that competency can be validated by two

possible methods:
• Actual observable behaviour; and
• The absence of error.
To meet the requirements, it is only necessary to formalise a process in which a

supervisor documents these two points after observing the individualÊs day-to-
day performance.
Competencies refer to what an individual is capable of performing and includes

cognitive skills such as decision making. It also includes interpersonal skills as
well as the psychomotor or technical skills associated with nursing procedures.
This may be achieved through formal education and acquired by experiences and
practices.
There are three standards of competence expected of a nurse:

(a) Applying knowledge and skills at the appropriate level for a particular
situation;
(b) Demonstrating responsibility and accountability in actual practice and
problem solving; and
(c) Restricting and /or accommodating practice if the nurse cannot safely
perform the essential functions of the role due to mental or physical
disabilities.

• The Patient Classification System predicts the nursing time required for a
specific or a whole group of patients.
• The number of staff and patients in your staffing pattern determines the
amount of nursing time available for patient care.
• The scheduling of staff is the responsibility of the nurse manager, who must
take into consideration the patientÊs need and intensity, volume of patients
and the experience of the staff.
• Self-scheduling could increase staff morale and professional growth but for it
to be successful would require clear boundaries and guidelines.
Functional nursing Staffing pattern

Patient-centred care Team nursing
Self scheduling
1. Florence Nightingale is known as the .

(a) Lady with the Lamp.
(b) Lady of the Lamp.
(c) Lady in the Mirror.
(d) Lady of Medicine.
2. The following statements are true about the Patient Classification System
(PCS) EXCEPT:
(a) It is measurement tool used to articulate the nursing workload for a
specific patient over a period of time.
(b) It is necessary to determine the patient's needs.
(c) It is useful for both individual patients as well large patient groups.
(d) It is a process to implement the monthly work schedule.

You are a nurse manager of a new unit for stroke patients which consists of
10 patients only. What would you consider when planning for staffing for
this unit?
Ellis, J. R., & Hartley, C. L. (2005). Managing and coordinating nursing care
(4th ed.). Philadelphia, Lippincott William & Wilkins.
practice from concept to reality. Aspen Advisor for Nurse Executives,
15(5) 6–9.

functions in nursing theory and application (5th ed.). Philadelphia: Lippincott
William & Wilkins.
Nelson, J. W. (2000). Consider this..Models of nursing care: A century of

vacillation. Journal of Nursing Administration, 30(4), 156, 184.

literature. Nursing Economics, 18(3), 124–136.

Topic Models of Care
4 Delivery
System
LEARNING OUTCOMES
1. Discuss the four models of care delivery systems; and
2. Formulate a standard care plan using clinical pathways.
INTRODUCTION
Each nursing care delivery model has advantages and disadvantages, and none is
ideal. Some methods are suited to large institutions, whereas other systems may
work best in a community setting. Managers in any organisation must examine
the organisational goals, the unit objectives, staff availability and the budget
when selecting a care delivery model.
In order to ensure that standard quality nursing care is provided to patients,

work must be organised. The decision on which delivery model is to be used is
based on the needs of the patients and the availability of competent staff in
different skill set levels.
As a manager in your area, you are responsible for planning and implementing
the model and evaluating its outcomes. First, you must make sure that you have
enough staff to execute the model. Then, you have to use reinforcement to
engage your staff in the implementation process. Continuous monitoring should
also be done to evaluate their performance.

50 TOPIC 4 MODELS OF CARE DELIVERY SYSTEM
This topic discusses the four strategies of a care delivery system: functional
nursing, team nursing, primary nursing and patient–centred care.
4.1 HISTORICAL PERSPECTIVE

There are four (4) models under the historical perspective (see Figure 4.1).
Figure 4.1: Four different models under the historical perspective
(a) Functional Nursing

This model (see Figure 4.2) was introduced during World War II when
there was a significant shortage of nurses in the United States. In the
Functional Nursing Model, nursing work was divided into functional units
that are then assigned to one of the team members. In this model, each care
provider has specific duties or tasks such as the serving medication nurse
or admissions nurse. Decision-making is usually at the level of the head
nurse or charge nurse.
(i) Advantages
This model can be utilised for a large number of patients. While it
makes use of other types of health care workers when there is a
shortage of nurses, patients are likely to have care delivered to them
in one shift by several staff members.
(ii) Disadvantages
On the other hand, to a patient, care may be disjointed. In this model,
the patient becomes the sum of the tasks of care required rather than
holistic care.

TOPIC 4 MODELS OF CARE DELIVERY SYSTEM 51
Figure 4.2: Functional nursing model

Adapted from Heidenthal (2003)
Now, let us consider another model.
(b) Team Nursing

The model of team nursing was developed after World War II, in an effort
to utilise nurses, as well as to ease the shortage of nurses that most hospitals
were experiencing. This model of care delivery assigns staff to teams that
then are responsible for a group of patients (see Figure 4.3). A unit can be
divided into two teams and each team is led by a registered nurse. The
team leader supervises and coordinates all the care provided by those on
the team. The team leader is also responsible for providing professional
direction to those on the team with regards to the care provided.
(i) Advantages
These models require a good team leader with very good delegation
and supervisory skills. Therefore, the RN can easily work together as
a group.
(ii) Disadvantages
Communication in this model can, however, be complex as there is
shared responsibility and accountability, which can cause confusion
and lack of accountability. These factors contribute to RN
dissatisfaction with this model. It can also lead to the patient feeling
fragmented and depersonalised.

Figure 4.3: Team nursing model

Adapted from Heidenthal (2003)
(c) Primary Nursing

Primary Nursing is a care delivery model that clearly delineates the
responsibilities and accountability of a RN. The registered nurse will be the
primary provider of the care to patients. Figure 4.4 shows the primary
nursing model.
In primary nursing, the elements are divided into:

(i) Allocation and acceptance of individual responsibility for the decision
making;
(ii) Assignment of daily care by the case method;
(iii) Direct person-to-person communication; and
(iv) One person operationally responsible for the quality of care
administered to patients on a unit 24 hours a day, 7 days a week.
(Manthey, 1980)
The primary nurse has the authority, accountability and responsibility to

provide care for a group of patients.
(i) Advantages
This model provides an advantage to patients and families whereby
they are able to develop a trusting relationship with the nurse. There

is a holistic approach to care, which facilitates continuity of care rather

than a shift-to-shift focus. Nurses who practise this model have
adequate time to provide necessary care and find this model
professionally rewarding because it provides the authority for
decision-making to the nurse at the bedside.
(ii) Disadvantages
However, one of the disadvantage of this model is it requires high
cost because there is a higher RN skill mix. The person making out the
assignments needs to be knowledgeable about all patients and staff to
ensure appropriate matching of nurse to patient. Nurse-to-patient
ratio must be realistic to ensure there is enough nursing time available
to meet the patient care needs.
Figure 4.4: Primary nursing model

Heidenthal (2003)
(d) Patient-centered Care or Patient Focused Care

This model focuses on patient needs rather than staff needs. In this model,
the required care and services are brought to the patient. The beauty of this
model is that all patient services are decentralised to the patient area,
including radiology and pharmacy services. Staffing is based on patient
needs. There is an effort to have the right person to do the right thing. The
care team includes other disciplines to plan for the care of the patient,
whereby they have to collaborate to ensure that the patient receives the care
needed.

(i) Advantages
This model is the most convenient model for patients as it expedites
services to the patients. However, it can be extremely costly to
decentralise major services in an organisation.
(ii) Disadvantages
The disadvantage is that some staff have perceived the model as a
way of reducing RNs and cutting costs.
You will get a clearer picture of this model by studying Figure 4.5.
Figure 4.5: Patient-centred care model

Heidenthal (2003)
ACTIVITY 4.1
Each model has its strengths and weaknesses that should be considered
when deciding which one to implement. Based on several different care
delivery models explained above, choose the best model that you think
can be implemented in your area and justify why you would choose
that model.

4.2 CARE DELIVERY MANAGEMENT TOOLS

In the 1990s, hospitals looked for opportunities to reduce costs through reduction
in the length of stay (LOS). Clinical Pathways, care management and disease
management surfaced as significant strategies.
4.2.1 Clinical Pathways

Clinical Pathways are care management tools that outline the expected clinical
course and outcomes for a specific type of patient. Pathways are often done by
day and for each day expected outcomes are articulated and patientÊs progress
is measured.
In this management tool, the pathways include multidisciplinary orders of care,

including orders from physicians as well as nursing and other health care
professionals such as physiotherapists and nutritionists for a group of patients
with a specific condition or treatment.
Clinical pathways reduce the patient's length of stay (LOS) and are widely used
not only to enhance outcomes but also to contain costs within a constrained
length of stay (Lagoe, 1998).
Patient Group
This is a homogeneous group of patients identified by a medical diagnosis,
diagnostic-related group (DRG) or surgical procedures for which usual processes
of care are similar. Among its features are:
• HIGH VOLUME: Increase total number of patients admitted with the same
diagnosis.
• HIGH RISK: Need immediate treatments compared to other diseases.
• HIGH COST: Higher cost for treatment, for example, total knee replacement.
• HIGH LOSS: The standard care plan in the clinical pathway will shorten the
length of stay in the hospital.
• LARGE VARIATION IN PRACTICE: Pathways also allow for data collection
of variances to the pathways. The data can then be used to look for
opportunities for improvement in hospital systems and in clinical practice.
(i) Advantages
Clinical Pathways are powerful tools for managing care. They are very
instructive for new staff, and they save significant amount of time in the

process of care. The implementation of clinical pathways will improve care

and shorten the length of stay for the population on the pathways.
(ii) Disadvantages
The problem arises during the development of the multidisciplinary
pathways as it requires a significant amount of work to gain consensus
from various disciplines on the expected plan of care.
For an example of a formulated clinical pathway, please refer to Table 4.1.
Table 4.1: Clinical Pathway for Acute Asthma in Adults

Care Emergency Medical Ward Medical Ward Medical Ward Medical Ward
Categories Medicine on Day 1 Day 2 Day 3 Day 4
Admission
Daily Patient will: Patient will: Patient will: Patient will: Patient will:
outcomes • Maintain • Maintain clear • Breathing • Effective • Effective
clear airway airway pattern and rate breathing breathing pattern
• Maintain • Maintain return to pattern and cough
oxygen oxygen saturation baseline • Able to • Maintain PEF
saturation >95% • Maintain cough post nebuliser
>95% • Achieve PEF PEF post effectively >75%
• Achieve post nebuliser nebuliser >75% • Maintain • Have stable
PEF post >75% • Have stable PEF post vital signs
nebuliser • Experience vital signs nebuliser >75% • Able to use
>75% resolution of acute Maintain • Have stable inhaler/
• Experience respiratory distress hydration vital signs aerochamber
resolution of • To restore lung – good urine • Understand correctly
acute function to the best output inhaler • Patient and
respiratory possible level as technique/ family understand
– moist
distress soon as possible aerochamber regarding
mucous
• Have • Have stable membranes – medications
stable vital vital signs instruction
• Able to
signs
• Maintain practise – recognition
• Patient controlled of acute
– hydration
and family breathing attack
good urine
understand exercise and
output – action taken
the diagnosis coughing
– moist during attack
and ongoing technique
treatment Mucous • To prevent
membranes early relapse
• Understand
nature of disease
• Able to use
peak flow meter

4.2.2 Case Management

Case management is a second strategy to improve patient care and reduce
hospital costs through coordination of care. A case manager is responsible
for coordinating care and establishing goals preadmission through discharge
(Del Togno Armanasco, Hopkin & Harrer, 1995).
For example, in a patient with post-surgery case, if the patient has not met
ambulation goals according to the clinical pathway, the case manager would
work with the physician and other health care professionals to determine what is
preventing the patient from achieving the goal.
To obtain more information on case management, please refer to these websites:

http://www.casemanagement.com/casemanager/reference
http://www.ana.org
• Patient Classification System (PCS) predicts the nursing time required for
specific and whole groups of patients.
• The number of staff and patients in your staffing pattern determines the
amount of nursing time available for patient care.
• Case management and clinical pathways are care management tools that
have been developed to improve patient care and reduce hospital costs.
• Whatever staffing variations are chosen, it is critical to assess its effect on
patient care and finances.
Clinical pathway Staffing pattern

Functional nursing Team nursing
Patient-centred care

1. The following statement is true about Patient Classification System (PCS)

EXCEPT:
(a) It is a measurement tool used to articulate the nursing workload for a
specific patient over a period of time.
(b) It is necessary to determine the patient's needs.
(c) The Factor system is a type of PCS.
(d) It is a process to implement the monthly work.
2. There are four models under the Historical Perspective. Which one is
considered as TRUE?
(a) In the Functional Nursing Model, nurses work as independent units.
(b) The model of team nursing was developed after the World War II in
an effort to utilise the nurses and to ease the shortage of nurses that
most hospitals were experiencing.
(c) The primary nurse does not have the authority, accountability and
responsibility to provide care for a group of patients.
(d) The Patient-Centred Care or Patient Focused Care model is designed
to focus on staff needs rather than patient needs.
1. You are a nurse manager of a new unit for stroke patients which consists of
10 patients. What would you consider when planning for staffing for this
unit?
2. Based on the above scenario, choose the most appropriate model of

delivery care system and explain the advantages and disadvantages of the
model in relation to the scenario.
DISCUSSION (GROUP)
Formulate one clinical pathway in the small group based on high risk, high
volume and high cost in your hospital. You are required to show evidence of the
statistical data before proceeding to the clinical pathway.

Ellis, J. R., & Hartley, C. L. (2005). Managing and coordinating nursing care (4th
ed.). Philadelphia, Lippincott William & Wilkins.
practice from concept to reality. Aspen Advisor for Nurse Executives, 15(5) 6–9.

functions in nursing theory and application (5th ed.). Philadelphia: Lippincott
William & Wilkins.
Nelson, J. W. (2000). Models of nursing care: A century of vacillation. Journal of

Nursing Administration, 30(4), 156, 184.

literature. Nursing Economics, 18(3), 124–136.

Topic Managing Care
5
LEARNING OUTCOMES
1. Explain the five stages of the team process;
2. Discuss the concept of time management; and
3. Apply time management strategies to enhance personal productivity.
INTRODUCTION
Numerous studies have shown how nurses use their time. Most studies were
conducted on acute care nurses as they represent the majority of nurses. Only 30
to 35% of nursing time is spent on direct patient care (Scharf, 1997). 25% of a
nurseÊs time is spent on charting and reporting. The remaining time is spent on
admission and discharge procedures, professional communication, personal time
and providing care that could be provided by unlicensed personnel, such as
transportation and housekeeping (Upenieks, 1998).
Patricia Benner addressed the issues faced by new nurses as they struggle with
time management issues and explained the ways expert nurses deal with time
management using contingency planning. This contingency planning includes
approaches such as rapidly assessing patient needs, setting and shifting
priorities. They continuously evaluate routine standards and procedures.
Standard priorities include attending to radically abnormal vital signs, symptoms
of respiratory or circulatory compromise, intravenous medications running dry
and intravenous medication administration. Expert nurses learn to anticipate and
prevent periods of extreme workload within a shift.

TOPIC 5 MANAGING CARE 61
5.1 EFFECTIVE TEAM BUILDING
There is a well-known quote:

„The whole is greater than the sum of its parts‰
The above quote clearly shows the importance of effective team building, where
each member should be equally important, everyoneÊs voices and opinions are
heard and progress is made towards the same goals. Team members should
know each othersÊ strengths and weaknesses and continually develop their
knowledge and skills. The leader also plays a role by educating team members so
they know what to do, enabling them so they know how to do it and
empowering them by authorising them to do it (Harrington-Mackin, 1996).
An interdisciplinary team is formed comprising members with a variety of

clinical expertise, such as nurses, physicians and social workers to look at care
delivery from different viewpoints. Working with different backgrounds within a
team, the team leader should ensure that everyone contributes towards
accomplishing the goals. In an organisation, various types of committees are
developed to assist in communication. An ad-hoc committee is usually
temporarily formed for specific purposes to achieve short-term goals.
Meanwhile, standing committees may be mandated by organisational bylaws, for
example medical staff meetings.
5.1.1 Stages of Team Process

Tuckman and Jensen (1977) and Lacoursier
(1980) identified five stages of the team
process: forming, storming, norming,
performing and adjourning (see Figure 3.1).

62 TOPIC 5 MANAGING CARE
Figure 5.1: Five stages of the team process

5.1.2 Key Components of Effective Teams

The value of team building is to enhance the function in any one or all of the
following processes (Herman & Reichelt, 1998), as shown in Figure 3.2.
Figure 5.2: Some processes that can be enhanced through effective team building
Lewin (1951), McGregor (1960) and Argyris (1964) are among the few people
who have discussed the theories of effective teams. A great team accomplishes
the objectives of the group through the active participation of its team members.
Figure 5.3: Key components of effective teams

(a) Clearly Stated Team Purpose

The team members need to know the purpose of the team, goals and targets
to be accomplished. The leader must ensure everyone in the unit
understands the task and performs the correct procedures.
(b) Team Composition
The leader should recruit and hire talented people. Team members should
use their basic knowledge and experience working in different areas.
(c) Effective Communication
Clear communication between team members can resolve conflicts that
might occur.
(d) Active Participation
The leader should ensure that each member participates and contributes
especially during a discussion or brainstorming session.
(e) Active Plan
The plan that everyone should agree on and feedback by team members
and others affected by the teamÊs decisions is necessary in maintaining
team focus.
(f) Ongoing Assessment and Evaluation
Outcomes should be consistent and up to expectations. Staff who excel will
be rewarded. In addition, special coaching and reinforcement will be
provided in order to overcome weaknesses.
Table 5.1 shows the attributes that can make a team effective or ineffective.
Table 5.1: Attributes of Effective and Ineffective Teams
Attributes Effective Team Ineffective Team

Working • Informal, comfortable • Bored, tense, stiff
environment
Objectives • Well understood and accepted • Unclear, or many personal
agendas
Leadership • Shared, shifts from time to time • Autocratic, remains clearly
with committee chairperson
Conflict • Comfortable with • Uncomfortable with
disagreements disagreements
• Open discussion of conflicts • One group aggressively
dominates
Criticism • Frank, constructive • Embarrassing

You should visit this website for more information on effective teams:
http://www.accel-team.com
5.2 TIME MANAGEMENT
A majority of new nurses find it impossible to meet all of their patientsÊ needs as
these needs tend to be unlimited whilst time is limited. Time management
allows these nurses to prioritise care, decide on the outcomes and perform the
most important interventions first. Good time management does not only help
nurses work well but also improves the quality of their personal lives as it simply
means more time for family, friends and leisure.
Time management allows us to achieve more with the available time by

analysing which task is more important and how the time is currently being
managed. There is a simple principle, the Pareto Principle (see Figure 5.4), which
states that 20% of focused effort results in 80% of results, or conversely that 80%
of unfocused effort results in 20% of results only. This principle reminds us to
focus on the right activities so that we can achieve maximum results.

Figure 5.4: The Pareto principle
It sounds easy but why do some people find it hard to focus on the 20% effort?
There are several possible explanations on this matter. One reason for losing
focus is when you tend to execute too many tasks or projects simultaneously. To
overcome this problem, you should run lesser projects at one time so that every
project can get your undivided attention. It is even better to finish one project
first before you move on to the next one. Prioritising goals can also be helpful.
Another reason for suffering work overload is due to your inability to say „No‰.
Learning to say „no‰ to requests is difficult and sometimes can be unpleasant to
others. You have to consider whether there is time left to complete the requests. If
your time is limited, you can consider delegation or negotiation or state politely
that you do not have extra time.
5.2.1 Time Management Strategies
Figure 5.5: Five strategies of time management

(a) Goal-setting
The first step in any time management strategy is to shift from task
orientation to outcome orientation. Long-term goals cannot be achieved
overnight. Long-term goals are best when broken down to smaller realistic
steps, towards long-term goals. There may come a time when the outcome
is no longer realistic or should be shifted to a more realistic goal when
circumstances change (Reed & Pettigrew, 1999).
(b) Setting Priorities

After the goals have been decided, priorities are set which include
analysing which goals are more urgent and should be accomplished first.
However, there should be no question that life-threatening emergencies
should come first. These must be done no matter how short the staffing is.
It is imperative that nurses protect their patients and maintain both patient
and staff safety as well as perform the activities essential to the nursing and
medical care plans (Hansten & Washburn, 1998).
(i) First Priority: A Life-Threatening or Potentially Life-Threatening
Occurrence
Life-threatening conditions include a patient at risk to himself or to
others and a patient whose vital signs and level of consciousness
indicates potential for respiratory or circulatory collapse (Hansten &
Washburn, 1998). A patient whose condition is life-threatening is of
the highest priority and requires monitoring until transfer or
stabilisation.
(ii) Second Priority: Activities Essential to Safety

Activities that are essential to safety include ensuring the availability
of life-saving medications and equipment and protecting patients
from infections and falls. The activities also include asking for
assistance or providing assistance during two people transfers, or
turning and movement of heavy patients (Hansten & Washburn,
1998).
(iii) Third Priority: Activities Essential to the Plan of Care
Activities that are essential to the plan of care are those which lead to
the relief of symptoms or healing. They are the activities that, if
omitted, will hinder the patientÊs recovery. These activities include
nutrition and medication administration, ambulation, positioning and
so on.
(c) Organisation
Simply by having few a simple routines, you can save a lot of time in a day
and even enhance your efficiency. Examples of the routines are keeping a

neat workspace or arranging things in order or using „file management‰

rather than „pile management‰. Another matter that should be taken into
consideration is the keeping of linens, supplies and medications. The nurse
should give consideration to all aspects of the unit environment and get
together with co-workers to make a difference.
(d) Time Tools

Sometimes the events of the day can be very hectic as opposed to a
planned schedule. In such instances, you may find yourself responding to
events rather than prioritised goals. Each nurse must devise a method for
tracking care and organising time, as well as delegating and monitoring the
care provided by others. By using a time log to list work-related activities,
you can plan your activities ahead of time. The activity log should be used
for several days and behaviour should not be modified in the mean time.
The nurse should record every activity, from the beginning of the shift until
the end, as well as periodically noting their feelings while doing the
activities. After completing the log, the nurse should analyse whether the
time was spent wisely or some activities may require some adjustments.
(e) Dealing with Information

The first step in managing information is to assess the source. You will have
a better idea on how to deal with the information once you know the
sources of the data. You can then interpret the data and convert it into
useful information by eliminating any unnecessary or unneeded data.
5.2.2 Strategies to Enhance Personal Productivity

Time management is so flexible that it not only helps to organise your work life
but also your personal life as well. Sometimes, nurses feel that their work life is
so hectic due to rotating shifts, weekend work and stressful work experiences
that they have less quality time with family or to even spend a few minutes for
exercise. Let us consider these three strategies that would help enhance our
personal productivity.
(a) Create More Personal Time

There are three major ways to create time. The first one is to delegate work
to someone else. The disadvantage is you cannot control the outcome of the
task such as when or how the task gets completed. So, you might want to
consider delegating jobs that are boring and mundane. Another way to
make time is to eliminate chores or tasks that add no value. The last way is
to get up earlier in the day. The extra time from getting up an hour earlier
can be used to enrich life. Of course, you might feel tired and respond to the
fatigue by going to bed a little earlier. If a person does not try to go to sleep
earlier and the outcome of getting up early is fatigue, then the strategy is
not beneficial.
(b) Use Downtime

Downtime is referred to as the time that is seldom used in a day such as
waiting time. Calling ahead to verify appointments and arriving no more
than five minutes early can avoid it. During unavoidable waits, the time can
be filled with reading or writing handy materials.
(c) Control Unwanted Distractions

There are always unwanted distractions that might take you away from
your personal life. A few examples of distractions are unplanned phone
calls, low priority tasks and requests for assistance.
Table 5.2: Strategies for Avoiding Personal Time Distractions
Distraction Strategies
Unplanned phone call Use an answering machine or voicemail. Consider a humorous
message. Set a time to return calls.
Low priority task Say no to jobs that have little value or which you have little
interest.
Request for assistance Encourage them to be more independent. Decision to help
assistance should be conscious decisions, not drop-in
distractions.
ACTIVITY 5.1
Based on your experience working in a busy ward and as the team

leader of the unit, discuss strategies to plan the effective use of time and
prioritising your activities.
You should visit these websites for more information on time management:
http://www.daytimer.com
http://www.mindtools.com

• Effective teams and committees are essential communication aspects in an

organisation, especially in healthcare.
• Great teams have clear goals, open communication and an action plan; they
continuously evaluate the outcomes.
• The team leader is responsible for ensuring that team members contribute to
achieve the goals.
• Focusing on team membersÊ strengths and knowledge are two of the keys to
effective team building.
• General time management includes deciding your priorities, knowing your
resources, and focusing the efforts to achieve the goals.
• Planning effective time includes time estimates and environmental
considerations.
• Time management applies to oneÊs job as well as oneÊs personal life.
Team Group process

Time management
1. Which is the normal sequencing of group process?

(a) Forming, norming, storming, performing, adjourning.
(b) Norming, forming, storming, performing, adjourning.
(c) Forming, storming, performing, adjourning, norming
(d) Performing, adjourning, norming, forming, storming.

2. To maintain a conducive environment in team building, it is important to:

(a) have an autocratic management style by the leader.
(b) encourage creativity within the organisation.
(c) reward employees who consistently revise the teamÊs objectives.
(d) hold an evaluation session at the completion of the teamÊs duration.
3. Which of the following team roles is considered functional?

(a) Creator.
(b) Detailer.
(c) Pleaser.
(d) Controller.
4. Which of the following is the best description of consensus?

(a) Everyone in the group agrees with the decision 100%.
(b) All members of the group vote on the selected action.
(c) Every group member compromises.
(d) Every group member fully supports the decision once it is made.
5. All of the following are general time management strategies except

.
(a) waiting patiently.
(b) analysing time.
(c) focusing on priorities.
(d) having an outcome orientation.
6. Personal productivity can be enhanced by .

(a) analysing time, getting up an hour early, delegating unwanted tasks.
(b) getting up an hour early, answering your calls and inviting a friend in
to talk.
(c) analysing use of time, getting up early, waiting patiently.
(d) getting up an hour early and accepting all responsibilities without any
negotiation.

Al-Assaf, A. F., & Schmele, J. (1997). Total quality in healthcare. Boca Raton,
FL: St. Lucie Press.
Alfaro-LeFevre, R. (1995). Critical thinking in nursing. Philadelphia: Saunders.
AMC Q series curriculum. (1998). Albany, NY: Albany Medical Center, Quality
Management Department.
Bennis, W., Benne, K., & Chin, R. (1969) The planning of change. New York: Holt,
Rinehart, Winston.
Huber, D. (2000). Leadership and nursing care management. N.p.: Saunders.
Delmar Learning.
Koch, R. (1999). The 80/20 principle: The secret to success by achieving more
with less. NY: Doubleday.
Lamond, D., & Thompson, C. (2000). Intuition and analysis in decision making
and choice.

functions in nursing. Philadelphia: Lippincott.
Norris, S. P., & Ennis, R. H. (1989). Evaluating critical thinking. Pacific Grove,
CA: Midwet Publications, Critical Thinking Press.
Paul, R. W. (1990). Critical thinking: What every person needs to survive in a

rapidly changing world. Rohnert Park, California: Center for Critical
Thinking and Moral Critique.
Reed, C. R., & Pettigrew, A. C. (1999). Self management: Stress and time. St Louis,
MO: Mosby.
Scott, G. G. (1990). Resolving conflict with others and within yourself. Oakland,
CA: New Harbinger.

practice. Philadelphia: F.A. Davis

Topic Decision
6 Making
LEARNING OUTCOMES
1. Apply problem-solving theories to make good decisions and solve
complex problems;
2. Apply the concept of quality assurance, quality management and
quality improvement; and
3. Differentiate between quality assurance and quality improvement.
INTRODUCTION
Decision making is a vital skill that every nurse should have, especially nurse
managers, as it does not only involve managing and delivering care, but also
engaging in planned change. Healthcare institutions have already provided
certain guidelines on dealing with routine situations. However, exceptional
situations may occur at times and this difficult decision making requires a
mature sense of judgment.
Critical thinking is a complex process that has many definitions. Most agree that
critical thinking does entail an orderly investigation of ideas, assumptions,
principles and conclusions. Critical thinking is the process that guides scientific
reasoning, the nursing process, problem-solving and decision making. The
cognitive skills attributed to the critical thinking process include divergent
thinking, reasoning, reflection, creativity, clarification and basic support (Green,
2000).

74 TOPIC 6 DECISION MAKING
Organisational change is the type of change that often causes more stress or
concerns. Unfortunately, when organisational change is planned, employees are
often the last to know what the anticipated change is when they are frequently
the ones most affected by it. The staff nurse is expected to implement the new
care delivery system, but they may also be the last persons to know about the
change until it is implemented.
Conflict resolution is vital in change. In this module you will learn about the
process of conflict resolution and relate this to your experiences and daily
nursing practice.
6.1 FACTORS AFFECTING DECISION MAKING
Figure 6.1: Internal and external factors that affect decision making

TOPIC 6 DECISION MAKING 75
6.2 DECISION MAKING THEORIES
There are a few theories that can be utilised in decision making and these are
summarised in Table 6.1.
Table 6.1: Theories that can be Utilised in Decision Making
Theory Key Idea Application to Practice

Normative or • Used when information is • Situations that fall under
prescriptive objective, and routine this category can be handled
decisions are involved or the using the agency policy,
problem is structured. standard procedures or
• Options are known and analytical tools.
predictable.
Descriptive or • Used when information is • Situations that fall under
behavioural subjective, non-routine and this category are best
unstructured. handled by gathering more
• Uncertainty exists because data, using past experiences,
options or outcomes are either using creative approaches,
unknown or unpredictable. or following a group
process.
Satisficing • Decision maker selects the • This process is the most
solution that minimally meets expedient and may be the
the objective or standard for a most appropriate when time
decision. is an issue.
• It is the more conservative
method compared to an
optimised approach.
Optimising • Decision maker selects the • This process is more likely
solution that maximally meets to result in a better decision,
the objective or standard for a but it takes longer.
decision.
• Usually, this process involves
accessing the pros and cons of
each option and listing the
benefits and costs associated
with each option. The goal is
to select the most ideal
solution.
Source: Lancaster & Lancaster (1982)

6.3 DECISION MAKING PROCESS

The decision making process relies on five steps: identifying the problem;
exploring alternatives and considering their consequences; choosing the most
desirable alternative; implementing the decision; and evaluating the results.
Refer Figure 6.2.
Figure 6.2: Decision making process

6.4 GROUP DECISION MAKING

Group decision making is more likely to result in higher quality decisions.
Research findings suggest groups are more likely to be effective if members are
actively involved, the group is cohesive, communication is encouraged and
members demonstrate some understanding of the group process. The group
facilitator or leader should carefully select members on the basis of their
knowledge and skills to form an effective group. Individuals who are aggressive,
authoritarian, or manifest self-oriented behaviours tend to decrease the
effectiveness of the group.
There are a few advantages of utilising group decision making. For example,
with the different knowledge, skills and resources of members collaborating in
the process, new ideas can be generated. In addition, the implementation process
is easier to carry out with the commitment of the team members. To secure the
support of the group, the leader should maintain open communication with
those affected by the decision and be honest about the advantages and
disadvantages of the decision.
Group decision making also carries disadvantages and may not be appropriate in
all situations. The decision making process requires more time and this may not
be appropriate in some situations especially in a crisis situation requiring prompt
decisions. Another disadvantage relates to unequal power among the team
members. Dominant personality types may influence the more passive or
powerless group members to conform to their points of view.
ACTIVITY 6.1
Identify a current problem in healthcare. Use the problem-solving

process in a group to find a solution. Employ the nominal group
technique and the Delphi technique.
6.5 CRITICAL THINKING

A professional nurse has to learn the content of nursing, namely the ideas,
concepts and theories of nursing, on top of developing the knowledge and skills
to become disciplined, self-directed critical thinkers. Critical thinking is the
disciplined, intellectual process of applying skillful reasoning as a guide to belief
or action (Paul, Ennis & Norris,1990). In nursing, critical thinking for clinical
decision making is the ability to think in a systematic and logical manner with

openness to questions, and to reflect on the reasoning process used to ensure safe
nursing practice and quality care.
For a better picture of critical thinking, let us have a look at the model shown in
Figure 6.3.
Figure 6.3: The critical thinking model
Critical thinking is a concept that interweaves and links the others. Decision
making is not synonymous with problem solving. Decision making is a
purposeful and goal-directed effort that uses a systematic process to choose
among options. Not all decision making begins with a problem, sometimes it just
needs to identify and select options or alternatives. Problem solving, on the other
hand, includes a decision-making step and is focused on trying to solve an
immediate problem, which can be viewed as a gap between „what is‰ and „what
should be‰.
Critical thinkers strive to be clear, accurate and precise when they communicate
and their thinking is adequate for their intended purposes. Thus, it is important
for managers to assess their staffÊs ability to think critically and enhance their
knowledge and skills through staff development programmes, coaching and role
modeling. Establishing a positive and motivating work environment can enhance
attitudes and the disposition to think critically.

6.5.1 The Elements of Critical Thinking

All thinking, if it is purposeful, comprises the following elements of thought
(Paul, 1990) (see Table 6.2).
Table 6.2: Elements of Thought
Elements of Thought Description
Purpose or goal All reasoning has a purpose and requires clarity,

significance, achievability and consistency of purpose.
Central problem or question at All reasoning is an attempt to solve a problem, figure
issue something out or answer a question. To answer a
question or solve a problem, one must understand
what it requires.
Point of view or frame of All reasoning is done from a point of view. Reasoning
reference is improved when multiple relevant points of view are
sought and when those points of view are articulated
clearly, emphasised logically and fairly, and applied
consistently and dispassionately.
Empirical dimension Reasoning is only as sound as the evidence on which it
is based. The evidence should be clear, relevant,
accurate, adequate, fairly gathered and reported, and
consistently applied.
Conceptual dimension Reasoning is only as relevant, clear and deep as the
concepts that form it. Concepts should be clear, deep,
neutral and relevant.
Assumptions All reasonings are based on assumptions. Reasoning
can only be as sound as the assumptions on which it is
based. Assumptions should be clear, consistent and
justifiable.
Implications and consequences All reasoning has implications, consequences and
direction. Understanding the implications and
consequences is important to reason through a
decision or issue. One must consider the clarity,
completeness, precision, reality and significance of
articulated implications.
Inferences and conclusions All reasoning has inferences by which one draws
conclusions and gives meaning to the data. Reasoning
is only as sound as the inferences it makes and the
conclusions to which it comes. Inferences should be
clear and justifiable. Conclusions should be consistent,
profound and reasonable.

6.5.2 Holistic Approach to Critical Thinking

There are five holistic approaches to critical thinking as shown in Figure 6.4.
Figure 6.4: Five holistic approaches to critical thinking

ACTIVITY 6.2
Let us suppose that staff shortage is the biggest problem in your

hospital. Using critical thinking, how would you solve this problem in
terms of recruiting and retaining the staff?
You should visit these websites for more information on critical thinking:
http://www.critical-thinking.org
http://www.insightassessment.com
6.6 CHANGE AND CONFLICT RESOLUTION

There are many definitions of change. For simplicity, change can be defined as
„making something different from what it was‰ (Sullivan & Decker, 1997). Most
change is implemented for a reasonable purpose. Most organisational change is
planned, and most change is purposeful (Sebastian, 1999).
There are three types of change: personal change, professional change and
organisational change.
Figure 6.5(a): Personal change

Figure 6.5(b): Profesional change
Figure 6.5(c): Organisational change
6.6.1 The Change Process

The change process is shown in Figure 6.6.
Figure 6.6: The change process

(a) Assessment
(i) The purpose of and need for change can be identified from the
collection and analyses of data.
(ii) There are several sources for data collection and analysis: structural,
technological and people.
(iii) Structural problems may be in the form of physical space or
configuration of the space.
(iv) Technological problems may include a lack of wall outlets for
necessary equipment, poorly situated computer locations and limited
computer system interface ability.
(v) People problems may come in the form of personnel with inadequate
training to accomplish the goals, unwillingness to meet the goals, lack
of commitment to the organisation or lack of understanding on the
need for change.
(vi) Data analysis is used to identify the need for change and support the
potential solutions.
(b) Planning
(i) The most successful plan for change is where the individuals who will
be most affected are involved, satisfied and committed.
(ii) It is also important to explain how the change will be implemented,
although this may require modification as the implementation begins.
(iii) Expected outcomes must be identified and the plan to evaluate those
outcomes must be evident.
(c) Implementation of Change Strategies

Bennis, Benne & Chin (1969) identified three strategies to promote change
in groups or organisations:
(i) Power coercive approach – uses authority and threat of job loss to
gain compliance with change.
(ii) Normative re-educative approach – uses social orientation and the
need for satisfactory relationships in the workplace as a method of
inducing support for change.

(iii) Rational-empirical approach – uses knowledge as a power base. Once

workers understand the organisational need for change or understand
the meaning of the change to them as individuals and the organisation
as a whole, they will change.
(d) Evaluation of Change

(i) The effectiveness of the change is evaluated according to the
outcomes expected in the planning process.
(ii) The time interval for evaluation should be identified and allowed to
elapse before modifications are made and declarations of failure are
asserted.
(e) Stabilisation of Change

(i) The stabilisation of the change is completed once the evaluation is
determined.
(ii) Re-evaluation is planned after the first six months or one year since
implementation to ensure that stabilisation of the change has
occurred.
6.6.2 Conflict
An important part of the change process is the ability to resolve conflict. Conflict
allows a healthy discussion of different views and values, and adds another
dimension to quality patient care. Conflict can also be seen as a disagreement
about something of importance to two or more parties. Each party may or may
not be aware of the otherÊs conceptualisation of the meaning of the conflict; thus
both parties need to sit down and determine the existence and nature of the
conflict and the reasons it exists.
There are essentially seven methods of conflict resolution. The methods dictate
the outcomes of the conflict process as shown in Table 6.3.

Table 6.3: Advantages and Disadvantages of the Conflict Resolution Methods
Conflict Resolution Advantages Disadvantages

Technique
Avoiding – ignoring the Does not make a big deal Conflict can become bigger
conflict out of nothing; conflict may than anticipated; the source
be minor in comparison to of conflict might be more
other priorities important to one person or
group than others
Accommodating – One side is more concerned One side holds more power
smoothing or cooperating. with an issue than the other and can force the other side
One side gives in to the side; stakes not high to give in; the importance of
other side enough for one group and the stakes are not as
the other side is willing to apparent to one side as the
give in other; can lead to parties
feeling „used‰ if they are
always pressured to give in
Competing – forcing; the Produces a winner; good Produces a loser; leaves
two or three sides are when time is short and anger and resentment on
forced to compete for the stakes are high losing sides
goal
Compromising – each side No one should win or lose May cause a return to the
gives up something and but both should gain conflict if what is given up
gains something something; good for becomes more important
disagreements between than the original goal
individuals
Negotiating – high-level Stakes are very high and Agreements are permanent,
discussion that seeks solution is rather even though each side has
agreement but not permanent; often involves gains and losses
necessarily consensus powerful groups
Collaborating – both sides Best solution for the conflict Takes a lot of time; requires
work together to develop and encompasses all commitment for success
optimal outcome important goals to each
side
Confronting – immediate Does not allow conflict to May leave impression that
and obvious movement to take root; very powerful conflict is not tolerated;
stop conflict at the very may make something big
start out of nothing

According to Lewicki, Hiam and Olander (1996), there are five approaches to
negotiation: collaborative (win-win), competitive (win at all costs), avoiding
(lose-lose), accommodating (lose to win), and compromise (split the difference).
These five approaches to negotiation are influenced by the importance of
maintaining the relationship relative to the importance of achieving oneÊs desired
outcomes.
Figure 6.7: The importance of relationship versus the importance of outcome

Success of the selected techniques depends on several factors. Any issues might
have enormous impact on the technique selected and the level of success that will
be achieved. The trick for the nurse leader/manager is to determine what
conflicts require intervention and which techniques stand the best chance for
success.
SELF-CHECK 6.1
Assessment of Conflict
Based on the following assessment format, answer all the following
questions.
(a) What is (are) the issue(s) in the conflict?
(b) Are the issues based on facts? Based on values? Based on interests
in resources?
(c) Are the issues realistic?
(d) What are the goals of each conflicting party?
(e) What conflict management strategies, if any, have been used to
manage the conflict to date?
(f) What alternatives in managing the conflict exist?
(g) What are you doing to keep the conflict going?
6.7 MANAGING QUALITY

The quality management philosophy, especially in healthcare differs from other
evaluation techniques because it focuses on the customer instead of the provider,
prevention instead of inspection and the process instead of the person. Successful
quality management permeates the organisation and values a continuous process
of improved patient outcomes. With these values, it will ensure the survival and
competitiveness of healthcare providers.
Quality assurance (QA) emerged in health care in the 1950s, about the same time
as hospital-accrediting organisations were founded (AMC Q Series, 1998). QA
was first aimed to inspect health care institutions, mainly hospitals to achieve
minimum standards of care. The function of QA grew over time, as it became the
organisational mechanism for measuring performance against standards and
reporting incidents and errors, such as mortality and morbidity rates. QAÊs
methods consisted primarily of chart audits of various patient diagnoses and
procedures. The method was thought to be punitive, with its emphasis on „doing
it right‰ and did little to sustain change or proactively identify problems before
they occurred. However, it did help to accomplish the minimum standards of

performance.
The terms „quality management‰ (QM) and „quality improvement‰ (QI) have
evolved from the business philosophy known as total quality management. It
began in the manufacturing industry with W. Edwards Deming and Joseph Juran
in the 1950s. This approach was integrated into the healthcare industry in the
1980s when cost and quality of care pressures from health maintenance
organisations and other third-party payers increased along with competition for
patients (AMC Q Series, 1998).
Quality management refers to a philosophy that defines a corporate culture

emphasising customer satisfaction, innovation and employee involvement. QI
refers to an ongoing process of innovation, prevention of error, and staff
development that is used by corporations and institutions that adopt the quality
management philosophy. This proactive approach emphasises „doing the right
thing‰ for customers and the end the result of this method is to satisfy customers.
Many healthcare organisations prefer to use the term „quality management‰ or
„continuous quality improvement‰ because total quality improvement can never
be achieved. The term „performance improvement‰ (PI) is sometimes used
interchangeably with quality improvement, but usually emphasises improving
the activities of individuals or groups, not the systems.

Table 6.4 shows the differences between Quality Assurance and Quality
Improvement.
Table 6.4: Differences between Quality Assurance and Quality Improvement
Quality Assurance (QA) Quality Improvement (QI)

Philosophy „Doing it right‰ „Doing the right thing‰
Goal To improve quality To improve quality
Focus Discovery and correction of Prevention of errors
errors
Major tasks Inspection of nursing activities Review of nursing activities
Chart audits Innovation
Staff development
Quality QA personnel or department Multidisciplinary team
team personnel
Outcomes Set by QA team with input from Set by QI team with input from staff
staff and patients/customers
ACTIVITY 6.3
Due to the increasing number of patient complaints on the quality of

care, you have been asked to form a team to address these patient care
issues.
1. Describe the five stages of group process.
2. Discuss how you will encourage your team members to progress
through each stage.
6.7.1 Benefits of Quality Management (QM)

QM provides the benefits to healthcare providers in several ways. First, QM is
based on the philosophy of being better; things should be done right the first
time; improvement is always possible; and being better than the competitors.
This increases an organisationÊs chances of survival during highly turbulent
and competitive times. Second, QM helps in terms of customer loyalty by
maintaining quality in every interaction with the patients/customers. Customer
satisfaction is rooted in the way health professionals treat their patients/
customers and in the quality of their outcomes. Third, quality directs health
professionals to give their customers more than the basics so that customers will

recommend and demand the services. This is achieved by proactively seizing

opportunities to perform better, driving for quality consistently and
continuously, and not waiting for a problem to be pointed out or for pressure
from a competitor to improve. Fourth, QM involves everyone on the
improvement team and encourages everyone to make contributions. This style of
participative management enhances job satisfaction. Employees feel valued as
team members who can really make a difference.
6.7.2 The Quality Improvement (QI) Process

The QI process is structured to plan, implement, and evaluate changes in
healthcare activities. It involves six steps and can easily be applied to clinical
situations.
(a) Identify needs most important to the consumer of healthcare services

Nurse Managers or staff nurses may conduct interviews or survey patients
about their experiences during nursing care. The studies should not focus
on physical tasks only, but also interpersonal care as well.
(b) Assemble a multidisciplinary team to review the identified consumer needs

and services
Teamwork is important to develop an effective QI team. Consider briefing
or educating team members about their roles before starting the QI process.
(c) Collect data to measure the current status of these services

Various data tools can be used such as flowcharts, line graphs, histograms,
Pareto charts and fishbone diagrams.
(d) Establish measurement outcomes and quality indicators

Benchmarking is one way to evaluate the quality of outcomes for your
healthcare institution. It is done by comparing one agencyÊs performance
against that of similar organisations.
(e) Select and implement a plan to meet the outcomes

Change strategies should emphasise open communication and education of
staff affected by the new standards or outcomes.
(f) Collect data to evaluate the implementation of the plan and the
achievement of outcomes
If an outcome is not met, revisions on the implementation process are
needed. The nurse manager must also evaluate the work of the team
members and the ability of individual team members to work together
effectively.
ACTIVITY 6.4
You are the change agent of the unit tasked with implementing a new
approach on nursing care and maintaining the quality of care. Choose
one issue in your clinical practice and relate it with the quality
improvement process that you have already learned. Discuss the issue
in class.
• The decision-making capabilities of nurses may affect their employerÊs ability

to survive.
• Group decision making will contribute to higher quality decisions.
• The ability to make wise decisions improves with experience.
• Critical thinking involves examining situations from every viewpoint.
• Conflict management and resolution are important parts of the change
process.
• To resolve conflicts, parties need to identify their differences, priorities and
common goals; determine which conflict resolution is the most appropriate
and implement it.
• Quality improvement is a continuous process focused on maintaining
regulatory compliance and improving patient care processes and outcomes.
• Quality management strives to prevent errors through effective planning.

Change Group process

Conflict Quality assurance
Critical thinking Quality improvement
Decision making Quality management
1. Decision making is best described as

(a) the process one uses to solve a problem.
(b) the process one uses to choose between alternatives.
(c) the process one uses to reflect on a certain situation.
(d) the process one uses to generate ideas.
2. What is the most desirable conflict resolution technique?

(a) Avoiding.
(b) Competing.
(c) Negotiating.
(d) Collaborating.
3. Which of the following is the best description of consensus?

(a) Everyone in the group agrees with the decision 100%.
(b) All members of the group vote on the selected action.
(c) Every group member compromises.
(d) Every group member fully supports the decision once it is made.

4. All of the following are general time management strategies except

_______________.
(a) Waiting patiently.
(b) Analysing time.
(c) Focusing on priorities.
(d) Having an outcome orientation.
5. Personal productivity can be enhanced by _________________.

(a) Analysing time, getting up an hour early, delegating unwanted tasks.
(b) Getting up an hour early, answering your calls and inviting a friend in
to talk.
(c) Analysing use of time, getting up early, waiting patiently.
(d) Getting up an hour early, accepting all responsibilities without any
negotiation.
6. What is the most common source of conflict in todayÊs healthcare
organisations?
(a) Goals.
(b) Values.
(c) Resource allocation disputes.
(d) Competition.
1. The decision making process is a vital skill that every nurse manager
should have. Briefly describe, using an example, how the Decision Making
Theories can be implemented in your nursing practice.
2. Discuss the benefit of Quality Improvement Process in your healthcare

activities.

Al-Assaf, A. F., & Schmele, J. (1997). Total quality in healthcare. Boca Raton, FL:
St. Lucie Press.
Alfaro-LeFevre, R. (1995). Critical thinking in nursing. Philadelphia: Saunders.
AMC Q series curriculum (1998). Albany, NY: Albany Medical Center, Quality
Management Department.
Bennis, W., Benne, K., & Chin, R. (1969). The planning of change. New York:
Holt, Rinehart, Winston.
Huber, D. (2000). Leadership and nursing care management. Missouri: Saunders
Delmar Learning.
Koch, R. (1999). The 80/20 principle: The secret to success by achieving more
with less. NY: Doubleday.
Lamond, D., & Thompson, C. (2000). Intuition and analysis in decision making
and choice.
Lancaster, J., & Lancaster, W. (1982). Concepts for advanced nursing practice: The
nurse as a change agent.

functions in nursing. Philadelphia: Lippincott.
Norris, S. P., & Ennis, R. H. (1989). Evaluating critical thinking. Pacific Grove,
CA: Midwest Publications, Critical Thinking Press.
Paul, R. W. (1990). Critical thinking: What every person needs to survive in a

rapidly changing world. Rohnert Park, California: Center for Critical
Thinking and Moral Critique.

Reed, C. R., & Pettigrew, A. C. (1999). Self management: Stress and time. St Louis,
MO: Mosby.
Scott, G. G. (1990). Resolving conflict with others and within yourself. Oakland,
CA: New Harbinger.

practice. Philadelphia: F.A. Davis.

Law
7
LEARNING OUTCOMES
1. Define basic concepts and principles of law;
2. Describe the sources and types of law; and
3. Relate „tort law‰ with issues in nursing practice.
INTRODUCTION
The role of professional nursing has expanded rapidly within the past few years
to include increased expertise, specialisation, autonomy and accountability, from
both the legal and ethical perspectives. This has raised new concerns among
nurses and a heightened awareness of the interaction of legal and ethical issues.
Areas of concern include legal issues, professional acts and regulations,
employment rules and ethical principles.
This topic provides an overview of the legal system and specific doctrines used
by courts to define legal boundaries for nursing practice.
This topic is not meant to be a complete legal guide to nursing practice. Students
are advised to seek other legal textbooks.

TOPIC 7 INTRODUCTION TO LAW 97
7.1 DEFINITION OF LAW

The earliest notion of law was the pronouncement of a ruler acting according to
what he thought to be his „divine right‰. A workable definition of the term „law‰
would be those rules of human conduct, established and enforced by authority,
which prohibit extremes in behaviour so that one can live without fear for oneself
or oneÊs property.
7.1.1 Sources of Law
SELF-CHECK 7.1
In a democratic country like Malaysia, who makes and enforces the

laws?
There are many different sources of law affecting healthcare providers and
their practices. Some laws affect nurses personally, such as constitutional
amendments, whereas other laws such as administrative laws regulate nursesÊ
professional acts.
In Malaysia, the ruling Government elected by the people is the one tasked to
make and enforce laws. Article 160 of the Federal Constitution provides a three-
fold classification of the different types and sources of Malaysian Law as shown
in Figure 7.1.
Figure 7.1: Three types of Malaysian Law

98 TOPIC 7 INTRODUCTION TO LAW
(a) Written Law (Statutory Law/Public Law)

The Written Law consists of the Federal Constitution which is the supreme
law of the land and the Constitution of each state of the Federation of
Malaysia. The acts are passed by Parliament and various State Assemblies.
The subsidiary rules and regulations are made by the Ministers and other
persons by virtue of the powers given to them by Acts of Parliament or
State enactments.
(b) Common Law

A body of law is developed from an accumulation of judgments arising
from past cases or precedents. The body of case law that developed from
adjudication of kings and later of judges is known as the Common Law.
Common law or judge-made law is to be contrasted from statutory law.
Whenever a case comes up before a court, a decision is made by the court

upon the facts of the case before it. This legal decision may contain a
principle which would be used in subsequent cases as a guide or precedent.
Most of these precedents are recorded in volumes known as case reports.
These recorded precedents are referred to as the common law. Precedents
are created by the power of judges to interpret existing law, whether it is a
previous precedent or some legislation. By so interpreting they create new
precedents and so the common law grows.
(c) Customs or Practices

Customs or Practices deal with any custom or usage having the force of
law in the Federation. This includes usage derived from personal laws of
different communities e.g. adats of the Malays and the Hindu and Chinese
customary laws.
SELF-CHECK 7.2
What is your interpretation of law? Why must law exist?

7.1.2 The Malaysia Court Hierarchy

See Figure 7.2 for an overview of the Malaysia Court Hierarchy.
Figure 7.2: The Judicial System in Malaysia
The system of courts throughout Malaysia was established via Article 121 of
the Federal Constitution, the Courts of Judicature Act (revised 1972) and The
Subordinate Courts Act (revised 1972).
A court is a gathering, presided over by a judge or other person invested with

judicial power, which follows the rules of procedure prescribed for that court and
is in some cases, assisted by a jury. The judge, or where there is a jury - the judge
and jury, determines such matters as:
• Whether certain facts have been established;
• Where required, the legal obligations and rights of a party or parties;
• The punishment appropriate for criminal or other offences; and
• The interpretation of statutory provision, the provisions of a will, or of a
contract.
Every court has a specific jurisdiction or power to hear cases. The word
„jurisdiction‰ has two aspects;
• The subject matter before the court; and
• The geographical area which the Court covers.

In law, courts have the power to deal with matters that have been specifically
stated to be within a certain geographical area. Further, each court has certain
civil and criminal powers. On the civil side, it can only try actions involving
subject matter of a certain value. On the criminal side, courts are limited by the
punishment that they can impose.
Courts are arranged in a hierarchy, from the lowest courts (MagistrateÊs Courts)
to the highest courts (Supreme Court). Decisions made in the higher court have
precedence over decisions made in the lower courts. This means that when one
has received a judgment of a lower court, one can appeal to a higher court to
have the lower courtÊs judgment quashed, and either a different judgment made
or a new hearing granted. The decision of the higher court then applies, and is
binding on all courts lower in the same hierarchy in the jurisdiction. Precedent is
the word used to describe the system by which the common law is passed on to
influence later decisions.
7.1.3 Differences between Malaysian Courts

(a) The Federal Court
In Malaysia, the Federal Court is the highest court of the land. It is
essentially an appellate Court hearing appeals from the Court of Appeal
and the High Court. It also has the original jurisdiction to hear disputes
between the States of the Federation or between any State and the
Federation and it can decide whether any State or Federal law has been
made by the State or Federal government exceeding their authority.
Further, it can decide on any question on the Federal Constitution referred
to it by the Yang di-Pertuan Agong.
(b) The High Court

The High Court has an original, appellate and supervisory jurisdiction. In
its original jurisdiction it has the power to hear all civil and criminal
matters regardless of the amount or sentence involved. However in civil
matters, only matters above the jurisdiction of the subordinate Courts are
filed in the High Court.
Criminal cases have normally to be heard first in the MagistrateÊs courts by
way of a preliminary hearing before they can be brought to the High Court.
However, the Public Prosecutor may issue a certificate requiring the Court
before which the case is pending to send the case to the High Court directly
for trial.

In its appellate jurisdiction, the High Court hears appeals from the
Subordinate Courts. By virtue of its supervisory jurisdiction the High Court
may require any case in the Subordinate Courts to be brought before the
High Court for hearing.
(c) Sessions Court

A Sessions Court has the power to try all civil proceedings where the
amount in dispute or value of the subject matter does not exceed
RM100,000/–. However, parties may have agreement in writing to agree
that the Sessions Court shall have jurisdiction over any amount. The
Sessions Court has however no jurisdiction on matters relating to
immovable property (with some exceptions), specific relief, administration
and probate, legitimacy and guardianship of infants and divorce. In its
criminal jurisdiction, the Sessions Court can try all offences other than those
punishable by death.
(d) Magistrates Courts

First Class Magistrates have the power to hear civil proceedings where the
amount in dispute or value of the subject-matter does not exceed RM25,000.
A First Class Magistrate may also hear and determine appeals from the
PenghuluÊs Court. In his/her criminal jurisdiction, the judge can hear all
offenses for which the maximum term of imprisonment does not exceed 10
years or which are punishable with a fine only. He is empowered to try
offenses under Section 392 (robbery) and Section 457 (trespass) of the Penal
Code. The First Class Magistrate may pass any sentence allowed by law not
exceeding:
(i) 10 years of imprisonment;
(ii) A fine of RM10,000;
(iii) Whipping of up to 12 strokes; or
(iv) Any sentence combining any of the sentences above.
An appeal on the decision of the MagistrateÊs Court is dealt with by the

High Court.

Second Class Magistrates have the power to try original actions or suits of a
civil nature where the Plaintiff seeks to recover a debt or specific amount of
money not exceeding RM300. On the criminal side, a Second Class
Magistrate may try offenses where the maximum term of imprisonment for
those offences does not exceed 12 months imprisonment or which are
punishable with a fine only. A second class Magistrate may pass any
sentence allowed by law not exceeding:
(i) Six months imprisonment;
(ii) A fine of not more than RM1,000;
(iii) Any sentence combining either of the above; or
(iv) Any sentence combining any of the sentences above.
An appeal from a decision of the MagistrateÊs Courts is dealt with by the

High Court.
(e) The Juvenile Court

This is a special court under the Juvenile Act of 1947 (Revised 1972), which
is for offenders below the age of 18. The President of the Sessions Court
presides with the help of two assessors chosen from the public. Hearings
are conducted in an informal atmosphere and are not open to members of
the public. The Court has the power to try all offenses except those
punishable by death. Guilty offenders may be sent to an approved
institution or discharged upon a bond with or without sureties. Any person
aggrieved by any findings of the Court may appeal to the High Court.
(f) PenghuluÊs Court

PenghuluÊs Courts are peculiar to West Malaysia. A PenghuluÊs Court has
the power to hear civil proceedings where the amount sought to be
recovered does not exceed RM50 and in which all the parties are persons of
an Asian race and speak and understand the Malay language. On the
criminal side, the PenghuluÊs Court may only try offenses of a minor nature
which are specifically enumerated in his Kuasa (empowering document)
and which can be adequately punished by a fine not exceeding RM25. A
person charged in a PenghuluÊs Court may elect to be tried by a Magistrate
Court. An appeal against the decision of the PenghuluÊs Court may be
made to a First Class Magistrate.
(g) Native Court

Native Courts are part of the judicial system of Sabah and Sarawak. They
have the power to deal with matters concerning „native customs‰ where
the parties are local natives. The Native Courts have the power to try civil

and criminal matters cases arising from a breach of native law or custom
where all the parties are natives or, in respect of a breach relating to
religious, matrimonial or sexual matters where one of the parties is native.
(h) Tribunals
Apart from the main system of courts there are various bodies which are
often referred to as tribunals. These tribunals have varying functions and
procedures which are set out in the legislation that created them.
(i) The Industrial Court

Industrial Courts are special courts set up to deal exclusively with trade
disputes. A trade dispute is defined as „any dispute between employers
and workmen or between workmen and workmen or between employers
and employees which is connected with employment of any person‰.
However, parties cannot go directly to the Industrial Court. They have to
go to the Minister of Human Resources (previously known the Minister of
Labour and Manpower) who may refer such a dispute to the Industrial
Court. Though the Industrial Court is not part of the main system of courts,
the High CourtÊs supervisory powers may be invoked to examine the
decisions of the Industrial Court. If an employee is dismissed or terminated
and chooses to challenge such a dismissal or termination he can, as a
workman, take the matter up to the Industrial Court.
The Industrial Court deals with matters referred to it in a less formal way
than the High Court. Rules of evidence are applied rather liberally. The
Court pursues a nebulous ideal known as „social justice‰ in deciding upon
cases before it.
7.1.4 Types of Law

There are a number of ways to classify laws. Classifications are based on whether
the laws are substantive or procedural.
(a) Substantive Law

Substantive law is that part of the law which tells us what we can do, must
do, or must not do, as well as the interpretation of the law, setting out rights
and obligations, etc. It determines the specific wrong, harm, duty or
obligation that causes an action to be brought to trial. It is divided into two
sub-branches: civil law and criminal law.

Civil law in turn has many sub-branches such as constitutional law,

commercial law, contract law, bankruptcy law, administrative law and
family law. It recognises and enforces the rights of individuals and
organisations.
Criminal law defines crimes and punishment.
(b) Procedural Law

Procedural law includes the various legal procedures required to bring a
dispute to trial and determines the rules that parties must follow to litigate
a matter before a court. In other words, it regulates the statute of limitations
and the process for administrating evidence at a trial. This includes such
sub-branches as the law of evidence and court rules.
See Figure 7.3 for the types of law.
Figure 7.3: Types of law

In a nutshell
The legal system is a complex combination of laws, rules and regulations that
are created at both federal and state levels. Nurses must stay informed of the
legal scope of their nursing practice as society, as well as the nursing
profession, is bound to undergo changes. A basic knowledge of the law and
how it works would help nurses avoid litigation while giving them the
confidence to practise without fear or favour.
7.1.5 Differences between Civil and Criminal Law

Disputes of law arise when a person or body claims that another has done them a
wrong.
Criminal actions are instigated by the Crown (in the guise of the State, through
the police) claiming a person has committed a wrong against it by committing a
crime. A civil action is instigated by an individual, who claims that another
person has wronged (harmed) them, either physically, mentally or economically,
or is likely to cause such harm by the proposed actions.
Criminal cases are prosecuted by the State. They are officially designated. If the
prosecution is successful, the convicted person is punished. The Crown is not
interested in compensating the victim in these cases, only in punishing the
offender.
Civil cases, on the other hand are brought about mainly by:
• One person against another, claiming damage wrongfully inflicted on her or
him, or a debt owing to her or him, and seeking compensation from that
person. In this type of case the first person is suing (not prosecuting) the
other. The person suing is called the plaintiff; the person being sued is called
the defendant.
or
• A person seeking endorsement of a claim to certain rights and privileges as
against another. That person is called an applicant of the court and any
person or body opposing the claim is called the respondent.
The CrownÊs only interest here, through the judges, is that the contest in court
be carried out according to the established procedure and rules of evidence, it
acts as a referee in both types of case (the judges of course have the added role
of interpreting the law and determining the facts). Civil cases are designated,

the name of the plaintiff or applicant first, followed by that of the defendant
or respondent.
In criminal cases the prosecution has to convince the jury beyond a reasonable
doubt that the accused is guilty. This means that unless the prosecution has left
no reasonable doubt in the juryÊs mind as to the accusedÊs guilt, despite the
accuserÊs attempts to create that doubt, they must acquit.
In a civil case the burden on the plaintiff or applicant amounts to convincing the
court on the balance of probabilities. This is not as difficult as the standard of
proof for a criminal case. The court must find a defendant not liable unless the
plaintiff has proved his case to that standard; the defendant does not have to
prove his case, only throw doubt on the plaintiffÊs arguments.
Criminal law deals with wrongs which are committed against the state rather
than against individuals. This is reflected in the fact that offenders are prosecuted
by the state. The interest of criminal law is in the punishment of the perpetrator,
not in the fate of the victim, who must pursue remedies in civil actions.
It is rare for a charge of criminal negligence to be laid against a health worker. It

may, however be found where something has gone horribly wrong, with
unintended results and it is established that the health care in question either
intended some degree of harm to occur, or was so reckless with regard to human
life or safety that a jury finds their actions serious enough to amount to a criminal
act. There is no definition of criminal negligence in the legislation (where it
involves an unintended death, it may be termed involuntary manslaughter), so
we must look to case law for it.
7.1.6 Tort Law

The law of negligence, also known in the healthcare context as malpractice law, is
part of what is known as „tort‰ law. The term is derived from the old French
word meaning „wrong‰ and this branch of the law deals with injuries caused by
one person to another. The doctrine of negligence applies to all areas of human
activity, but its operation in relation to health care has some special features.
Tort law is one of the ways in which nurses, midwives and health visitors are
held accountable. It differs from other types of law in a number of ways.
Criminal law established standards on behalf of society, and when the rules are
broken society punishes the wrongdoer irrespective of the victimÊs position. The
wrong is committed against society as a whole. Tort law is concerned with the
relationship between individuals.

When mishaps occur, victims can choose whether they wish to sue the person
who caused the action. If they decide to sue, and in their case, they will receive
compensation, which is designed so far as possible to put them in the position in
which they would have been if nothing had happened to them. The major
function of negligence actions therefore, in health care as elsewhere, is to provide
compensation for the victims of accidents.
The second main function of negligence is to provide an incentive to practitioners

to attain a high standard of care. The fact that falling short of the proper
standards of care may lead to being sued and paying out money is thought to
deter poor practice.
The standard of care in negligence does not represent the quality of care that
nurses, midwives and health visitors should aspire to provide, it establishes the
basic standard of practice that patients are entitled to expect as a minimum.
• Legislative and legal controls have been established to clarify the boundaries
of professional practice and to protect patients.
• There are some definite answers and guidelines to assist nurses for legal and
legislation areas.
• However these controls are constantly evolving and nurses must continually
be aware of these changes as they affect the scope of practice.
Appellant Duty of Care

Appeal Libel
Assault Legislation
Battery Legislature
Burden of proof Negligence
Case Law Plaintiff
Contract Tort
Defamation

1. Ethics is a body of knowledge that deals with:

(a) Primarily legal aspects of health care.
(b) Trying to get individuals to behave correctly.
(c) The „shoulds‰ and „should nots‰ of individual behaviour or actions.
(d) Religion only.
2. Common law refers to:

(a) The Law that societies have in common
(b) Ethical ideas only
(c) Statutes
(d) Case law
1. According to Marquis & Huston, ethical dilemmas can be defined as having

to choose between two equally desirable or undesirable alternatives. How
far does this statement influence your decision making process?

8 Ethics
LEARNING OUTCOMES
1. Examine the acts and regulations related to the nursing profession;
2. Analyse key aspects of employment rules and how it affects nursing
practice;
3. Discuss the legal issues facing nurses related to patient care;
4. Analyse ethical theories and principles in health care; and
5. Explore ethical issues and dilemmas related to nursing practice.
INTRODUCTION
This topic is divided into four sections. Having learnt the types of law and the
differences between various types of law in the previous topic, you may now
study the standards of professional conduct set by the Malaysian Board of
Nursing. You will also learn about the law that applies to nurses.
The first section examines the role of nursing acts and regulations, and
employment rules in professional licensure and discipline. The second section
deals with legal implications and nurses duties and responsibilities. Basic ethical
concepts will be introduced in the third section. The last section deals with
ethical issues and dilemmas in nursing practice.

110 TOPIC 8 INTRODUCTION TO ETHICS
There are four main ways in which the law works to maintain nursing standards:
(a) Criminal law could be involved where the harm was deliberately or
recklessly caused. It is, for example, manslaughter to cause a patientÊs death
through recklessness or through intentionally committing an unlawful act
that causes death.
(b) The Nurses Act 1950 and Nurses (Amended) Act 1980 give the Malaysian
Nursing Board power to de-register nurses found guilty of professional
misconduct.
(c) Employers may, under the contracts that they have with each nurse,
discipline and dismiss the nurse.
(d) The law of negligence allows patients to sue nurses and their employers for
compensation, should they suffer loss through a nurseÊs carelessness.
8.1 STANDARDISATION OF PROFESSIONAL

CONDUCT
One of the primary functions of the Board of Nursing is to protect the public
from unqualified persons who attempt to practice the profession of nursing or
who pose potential harm to a patient through unsafe practices. Through such
mechanisms as the Nurses Act, standards of care and the code of ethics, the
board of nursing is able to ensure a degree of public safety where nursing care is
involved. The Nurses Act is a legal code and although stated in very general
terms, it does have the force of law and mechanisms for enforcement. Standards
of care and codes of ethics are not laws, but they have their own means of
enforcement. When a nurse violates either the standard of care or the code of
ethics (or both) frequently and with disregard, that person is not acting in a
professional manner. The Board of Nursing has the authority to discipline nurses
who are not acting in a professional manner. This discipline can range from a
reprimand to licensure suspension or even revocation.
8.1.1 Licensure
Licensure is the process by which an agency of a government grants permission
to an individual to engage in a given occupation. There must be evidence that the
applicant has attained a minimal degree of competency to ensure that public
health, safety, and welfare are reasonably protected. It defines not only the scope
of practice and the requirements for entry into practice, but also the penalties for
prescribed actions and for practising without a requisite license.

TOPIC 8 INTRODUCTION TO ETHICS 111
8.1.2 Board of Nursing

To regulate nursing practice in Malaysia, the Nursing Board Malaysia was
created. The Nursing Board Malaysia comes under the Nurses Act 1950. Nurses
Registration Regulations 1985 is a statutory body for nurses. It controls the
training, registration and discipline of nurses in Malaysia.
The aims of the Board are to:

• Establish and improve the standards of education and professional conduct
for nurses, midwives and public health nurses;
• Provide policy advice to organisations representing nurses and other
organisations relevant to nursing and the general public; and
• Develop and promote the nursing care plan and processes for patients in
institutions and the community.
The functions of the Nursing Board Malaysia are as shown in the following table.
Table 4.1: The Functions of the Nursing Board Malaysia
Function Description
Training • Approves training schools for nurses
• Approves the curricula for training
• Reviews the training curricula from time to time
Registration • Registers trained nurses in the General part of the Register for
Nurses
• Registers nurses in the supplementary parts of the Register for:
assistant nurses, mental health nurses, public health nurses,
community nurses
Discipline • The Board has disciplinary jurisdiction and is empowered to take
action against any registered nurse for breach of discipline as
provided in the Regulations.
Board Meetings • Examination Board meetings to approve the Nurses Registration
Examination results
• Nursing Education Committee Meetings to consider any matters
pertaining to training, curricula and examinations
• Nursing Evaluation Committee to process the application for
registration for foreign trained nurses (Malaysian nurses trained
overseas and foreign nurses)

Examination • Setting questions for examinations

• Appoints examiners
• Conducts markersÊ meetings
• Release examination results
Practicing • Issues annual practicing certificate
Certificates • Issues temporary practicing certificate to foreign nurses
Professional • Provide guidance to the profession on standards of professional
Conduct conduct.
In a nutshell
The state legislature creates the Nurses Act and grants the authority for a
Board of Nursing to administer and enforce the act, thus setting the legal
boundaries for the scope of professional nursing practice.
8.1.3 Contract of Employment

The relationship between parties may determine the limitations of liability in a
legal action to recover damages caused by wrongful or negligent acts. In some
employment situations nurses may be employees, whereas in others they may be
independent contractors and it is important to know the difference.
(a) Employer and Employee

Each person is personally liable for negligent acts. In addition, an employee
may make the employer liable as well. Generally speaking, the employer
has the „right to control‰ and to direct another in the performance of the
work, including the details and means by which the work is to be done. It is
not necessary that the employer actually directs or controls the way in
which the services are performed, it is enough that the employer is legally
entitled to do so.
A person becomes an employee, generally speaking, when he performs
services for another who has the „right to control‰ what is done and how it
is done. An employee is one who works for wages or salary in the service of
an employer. The power to discharge is that of the employer's.
Respondent superior (literally, „let the master answer‰) is a legal principle
that makes an employer liable for the wrongful acts of any employee. Also
called the master-servant rule, it can apply to the relationship between a
principal and an agent as well. For example, whenever a person (patient) is

injured by an employee (nurse) as result of negligence in the course of the

employeeÊs (nurse) work, the employer (hospital) is responsible to the
injured person (patient). In this situation the injured person (patient) may
sue both the employee (nurse) and the employer (hospital) and thus has a
better chance of being compensated for his injury. However, double
recovery is not allowed.
(b) Employer and Independent Contractor

The law defines an independent contractor as a person contracting with
another to do something, but not controlled by the other, nor subject to the
otherÊs „right to control‰ with respect to his or her physical conduct in the
performance of the undertaking (work or service). Applying this definition
to the nurse, it becomes apparent that if a nurse is subject to control by
another merely for the result of the work, and not for the means by which
the research is reached, she or he may be an independent contractor. Private
duty nurses are independent contractors, answerable for any wrong they
may commit, and the hospitals in which they are working is not liable.
8.2 WHAT KIND OF LAW APPLY TO NURSES

Nurses are, of course, citizens and subject to, and entitled to take advantage of,
the law. They may, for example, use the law to protect themselves against their
employers, perhaps for discrimination and unfair dismissal, or not providing a
safe place and system of work, and adequately trained colleagues. They may use
the law against patients who assault them or sue those who defame them.
Nurses can be, and have been, prosecuted for committing crimes. These range
from assaults and theft of patientsÊ property to manslaughter where a nurseÊs
recklessness may have caused a patientÊs death. While patients sue using the civil
law, it is normal for the police to bring prosecutions under the criminal law. In
criminal law, the prosecution must prove their case „beyond all reasonable
doubt‰. That is why some prosecutions are not begun because the prosecutorÊs
advice is that there is insufficient evidence for conviction. This can occur in cases
where nurses are accused of abusing patients where there is insufficient
supporting factual evidence.
In civil cases and professional and employerÊs disciplinary procedures, the court
of tribunal only has to be satisfied „on a balance of probabilities‰, although they
will take into account the seriousness of the consequences for the people
involved, such as loss of employment. So the same nurse may not be prosecuted
for abusing a patient or may be found not guilty but nevertheless have his or her
dismissal from employment approved by an industrial tribunal, or his or her

registration as a nurse may be withdrawn by the Malaysian Nursing Board,

making them liable to be sued by the patient for assault or negligence.
A nurse will only be liable for negligence if he or she had negligently caused loss
to someone to whom she or he owed a duty of care. To be liable for negligence it
is not enough that there was a duty of care, there must also have been a breach of
the standard of care. These standards govern the actions of the nursing
profession. A nurse is not negligent when he or she acts in the way that
reasonably competent members of his or her profession would act. The court
listens to the expert witness, from the profession concerned, who describes the
appropriate standard of care and what any reasonable competent nurse would
have done in such circumstances. Harm or loss must be experienced, and it must
have been caused by the negligent act. The law requires that the breach of the
standard of care causes the loss. The particular negligent conduct does not have
to be the sole main cause. It will be enough that it had an effect that was not
insignificant or trivial.
An example of a negligence case is given below.
A woman was admitted to hospital having taken an overdose of drugs. Her

stomach was pumped out and she was transferred to a psychiatric ward
where she was diagnosed as having a depressive illness with paranoid
features. She had delusions about snakes, God and death. The information
was not put in the nursing notes. A few days later, although she seemed much
improved, she went into the toilet, took out some matches and set fire to her
shirt. She was badly burned.
In this case, the nurse was found to be negligent as:
(a) The nursed owed the woman a duty of care while she is in hospital;
(b) There was a breach of standard of care as relevant information was not
documentated; and
(c) There was a loss, i.e. physical injuries from the burns.
In a nutshell
Three elements must be found in negligent cases:
(a) The nurse must owe the patient a duty of care;
(b) There must be a breach in the care; and
(c) The patient must suffer some kind of loss.

8.2.1 Intentional and Unintentional Tort

While professional negligence can be considered as an unintentional tort, assault,
battery, and defamation are intentional torts. The differences between assault
and battery are given in Table 8.2.
Table 8.2: Differences between Assault and Battery
Assault Battery
Issue of consent does not arise. Defendant's act is done without the
plaintiffÊs consent.
Plaintiff experiences reasonable apprehension Physical contact between defendant and
of a force upon his person. plaintiff.
The tort protects one from the threat of any The tort protects one from physical contact,
physical violence, as well as to maintain a be it violent or not, as long as it is an
personÊs mental well-being. unnecessary and unauthorised contact.
The key point is patient consent. The nursesÊ checklist for making sure informed
consent is taken includes:
(a) Disclosure
Patient is informed of current medical status, course of treatment, risks
involved, benefits, alternatives, etc.
(b) Comprehension
Patient understanding.
(c) Competence
The patient is competent enough to understand, reason and deliberate
information and make decisions.
(d) Voluntariness
The patient was not subject to force, coercive influence or manipulation.
There are two types of defamation: libel and slander. While in libel, the
statements are in permanent form i.e. written or printed statements; slander is
usually in transitory form i.e. speech or gestures. Thus it may not be actionable as
compared to libel as it must have proof of damage. Patient confidentiality thus is
very important. Nurses owe a duty of confidentiality in respect of the patientÊs
information acquired in their capacity as a nurse and may only disclose
information in certain circumstances i.e. case discussion for management of
patient, statutory requirement, etc.

8.3 BASIC ETHICAL CONCEPTS

Virtually everyone agrees that doing good and avoiding harm are relevant to
ethics. Thus, the ethics of health care professionals has been given special
emphasis. In the Malaysian Code of Professional Conduct, six provisions are
listed that state the ethical obligations and duties of nurses. The provision
describes such things as 1) the nurseÊs fundamental commitment and values 2)
duties related to duty and loyalty and 3) collaborative efforts with other health
care professions. Although they are not legally enforceable as laws, consistent
violations of a professional code indicate unwillingness by the individual to act
in a professional manner, which often results in disciplinary actions ranging from
reprimands and fines to suspension and revocation of licensure.
Many nurses envisage ethics as dealing with principles of morality and thus
what is right or wrong. A broad conceptual definition of ethics is that ethics is
concerned with motives and attitudes and the relationship of these attitudes to
the good of the individual. Ethics may be distinguished from the law as ethics
concerns the good of an individual within society while law concerns society as a
whole. Law can be enforced through courts and statutes while ethics are enforced
via the ethics committee and a professional code of conduct.
Table 4.3 shows the distinctions between law and ethics.
Table 8.3: Distinction between Law and Ethics
Law Ethics
Source External to oneself; rules and Internal to oneself; values, beliefs
regulations for society. and individual interpretations.
Concerns Conduct and actions – what did the Motives and attitudes – why did
person do. the person act as he or she did.
Interests Society as a whole. Individuals within a society.
Enforcement Courts, statutes, Nursing Board. Ethics committee, professional
organisation.

8.3.1 Ethical Theories

Many different ethical theories have evolved which are mostly considered
normative approaches to ethics with two broad categories:
• Deontological theories – emphasis on the dignity of the human being
• Teleological theories – governed by the consequences of our actions
Ethical theories are important because they form the essential basis of knowledge
from which to proceed. In addition to ethical theories, there are several key
principles which will be discussed below.
8.3.2 Ethical Principles

The five major ethical principles that should be considered are shown in Figure 8.1.
Figure 8.1: Five major ethical principles
(a) Autonomy
The autonomy principle addresses personal freedom and the right to
choose what will happen to oneÊs own person. The legal doctrine of
informed consent is a direct reflection of this principle. However autonomy
is not an absolute right. Under certain circumstances, the individualÊs rights
do not prevail over the rights of others. For example, a nurse has the right
to refuse care to a patient because of religious belief; however, if the safety
of the patient is jeopardised because of the lack of care, the nurse may

suffer legal consequences if care is not provided. The principle of autonomy

underlies the first statement in the Professional Code of Conduct.
(b) Beneficence and Non-maleficence

Beneficence is the duty to help others by doing what is best for them. This
also applies to the principle of non-maleficence, or do no harm. Thus not
only does one have the duty to do good but also the duty not to inflict harm
or to risk harm to others. Many nurses find it difficult to follow these
principles when performing treatments and procedures that bring
discomfort and pain to patients. The principle of beneficence may be chosen
because even pain and suffering can bring about good for the patient.
(c) Veracity
Veracity concerns truth telling and incorporates the concern that
individuals should always tell the truth. Lying or deception creates a
barrier between people and prohibits both meaningful communication and
the building of relationships. Recognising that communication is the
cornerstone of the nurse-patient relationship, it is obvious that nurses must
be truthful in order to communicate effectively with patients.
(d) Justice
Justice is the obligation to be fair to all people. The concept is often
expanded to what is called distributive justice, which specifically states that
individuals have the right to be treated equally regardless of race, sex,
marital status, medical diagnosis, social standing, economic level or
religious belief. It requires that the person or patient be treated according to
what is fair. The implication is that patients with the same diagnosis should
receive the same level of care. However nurses often face the challenge of
allocating scarce resources and supplies fairly.
In a nutshell
Ethics deals with the right and wrong of situations and has no mechanism of
enforcement, whereas laws are man-made rules that regulate society and are
enforceable. All ethical principles presuppose a basic respect for persons.

ACTIVITY 8.1
Read the following hypothetical case and discuss the answers for the
following questions with your coursemates.
Puan Aminah is a 75 year old woman who has terminal ovarian cancer.
During the course of her radiotherapy, she sustains third degree
radiation burns to her lower abdomen. Her wounds are extensive and
deep, requiring frequent wound irrigation. Despite being given pain
relief before each course of treatment, Puan Aminah finds it very
painful. She wants the treatment discontinued.
(a) Discuss the situation in terms of beneficence and non-maleficence.
(b) What is the nurseÊs responsibility in assisting the patient to
maintain autonomy?
(c) How should the nurse deal with conflicting principles?
8.4 ETHICAL DILEMMAS

Ethical dilemmas can be defined as having to choose between two equally
desirable or undesirable alternatives (Marquis & Huston 1994). Curtin (1982)
maintains that for a problem to be an ethical dilemma, it must have three
characteristics:
• The problem cannot be solved using empirical data;
• The problem must be so perplexing that deciding what facts and data to be
used in making the decision, becomes difficult; and
• The results of the problem must affect more than the immediate situation;
there should be far-reaching effects.
By the very nature of an ethical dilemma, there is no good solution, and the
decision made often has to be defended against those who disagree with it. The
ethical decision making process provides a way for nurses to answer key
questions about ethical dilemmas and to organise their thinking in a more logical
and sequential manner.

8.4.1 Ethical Decision Making Process

The chief goal of the ethical decision making process is determining right from
wrong in situations where clear demarcations do not exist or are not apparent to
the nurse faced with the decision.
The following five-step ethical decision making process is presented as a tool for
resolving ethical dilemmas.
Step 1: Collect, analyse and interpret data

• Obtain as much information as possible.
• Get information related to the patientÊs wishes, the familyÊs wishes and the
extent of the physical or emotional problems causing the dilemma.
• After collecting information, bring the pieces of information together in a
manner that provides the clearest and sharpest focus to the dilemma.
Step 2: State the dilemma

• The dilemma needs to be stated as clearly as possible in terms of the key
ethical issues.
Step 3: Consider choices of action

• List all possible courses of action that can resolve the dilemma without
considering the consequences.
Step 4: Analyse the advantages and disadvantages of each course of action

• By considering the advantages and disadvantages, the nurses should be able
to pare the choices down to the few realistic choices of action.
Step 5: Make the decision

• This is the most difficult part of the process. The decision should be based on
sound ethics.

ACTIVITY 8.2
What would you do?
Encik Ahmad, 90 years old, was hospitalised due to dehydration,

vomiting and a urinary tract infection. He has senile dementia with a
tendency to wander. At high risk for falls, he already has a history,
with a broken hip last year. He was found wandering in the
neighbourhood on two separate occasions this year.
An intravenous line was inserted to correct his dehydration. Concerned

that he might fall, dislodge the line or wander off somewhere, the staff
believes it is best to restrain him. However Encik Ahmad refuses and is
adamant he does not want to be restrained.
(a) State the ethical dilemma.
(b) What are the choices of action and how do they relate to ethical
principles?
(c) What decisions can be made?
In a nutshell
There are no clear or ideal solutions in ethical dilemmas and differences of
opinion often exist as an individual is forced to choose between two equally
favourable alternatives. At some point, nurses need to undertake the task of
clarifying their own values.
• Ethics offers no clear-cut answers, nor are there rules and guidelines that
cover all aspects of human life.
• The nurse must explore value systems and become expert in using ethical
principles and theories.
• Ethical principles exert direct control over professional nursing practice and
encompass basic premises from which rules are developed.

Autonomy Duty of care

Beneficence Legislation
Nonmaleficence Legislature
Veracity Negligence
Justice Plaintiff
Fidelity Tort
Defamation
1. Nonmaleficence actually means

(a) The nurse must take care of the patient
(b) There is negligence
(c) Not to harm the patient
(d) Malpractice
2. An intentionally false communication, either published or spoken, can be

termed as
(a) Assault
(b) Defamation
(c) Malpractice
(d) False imprisonment
Discuss the importance of the Nursing Board in enforcing and monitoring

nursing practice in Malaysia.

MODULE FEEDBACK
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1. E-mail your comment or feedback to modulefeedback@oum.edu.my
OR
2. Fill in the Print Module online evaluation form available on myINSPIRE.
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Centre for Instructional Design and Technology

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Faculty of Nursing and Allied Health Sciences

Copyright © Open University Malaysia (OUM)

Copyright © Open University Malaysia (OUM)

Module Writers: Raijah A Rahim

Moderators: Prof Dr T K Mukherjee

Developed by: Centre for Instructional Design and Technology (CIDT)

First Edition, June 2007

Copyright © Open University Malaysia (OUM)

Topic 1 Introduction to Management in Nursing 1

Topic 2 Leadership and Motivation 19

Topic 3 Managing the Ward and Clinical Area 37

Copyright © Open University Malaysia (OUM)

Topic 4 Models of Care Delivery System 49

Topic 5 Managing Care 60

Topic 6 Decision Making 73

Copyright © Open University Malaysia (OUM)

Topic 7 Introduction to Law 96

Topic 8 Introduction to Ethics 109

Copyright © Open University Malaysia (OUM)

Copyright © Open University Malaysia (OUM)

Copyright © Open University Malaysia (OUM)

As an open and distance learner, you should be acquainted with learning

Copyright © Open University Malaysia (OUM)

Table 1: Estimation of Time Allocation of Study Hours

TOTAL STUDY HOURS 160

Copyright © Open University Malaysia (OUM)

Topic 3: A nurseÊs ability to provide safe and effective nursing care to

Topic 5: Expert nurses deal with time management using contingency

Copyright © Open University Malaysia (OUM)

of professional conduct set by the Nursing Board Malaysia. In this

TEXT ARRANGEMENT GUIDE

Self-Check: This component of the module is inserted at strategic locations

Activity: Like Self-Check, the Activity component is also placed at various

Copyright © Open University Malaysia (OUM)

References: The References section is where a list of relevant and useful

Huber, D. (2000). Leadership and nursing care management (2nd Ed.)

Kelly, H. (2003). Nursing leadership and management. Canada: Thomson.

Copyright © Open University Malaysia (OUM)

Nelson, J. W. (2000). Consider this models of nursing care: A century of

Shullanberger, G. (2000). Nurse staffing decisions: An integrative review of the

Tappen, R. M. (2001). Nursing leadership and management: Concept and

TAN SRI DR ABDULLAH SANUSI (TSDAS)

Copyright © Open University Malaysia (OUM)

Which one do you prefer to be? It is difficult to distinguish between leadership

Copyright © Open University Malaysia (OUM)

„Management is efficiency in climbing the ladder of success; leadership

Imagine you are in a supervisory role as a head nurse or a team leader. A

1.1 PROCESS OF MANAGEMENT

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Figure 1.1: Meaning and principles of management

Planning can have a positive impact on organisational and individual

A manager of an organisation is usually familiar with the term „strategic

Copyright © Open University Malaysia (OUM)

Figure 1.2: Key steps in strategic planning

So, what is strategic planning?

Strategic planning is selecting and organising the institution in order to keep it

Copyright © Open University Malaysia (OUM)

potential threats and an internal assessment to identify its strengths and

The strategic management process is critical to the organisationÊs success.

The process of planning must involve managers and employees throughout an

Planning can have a positive impact on organisational and individual

There are two major types of organisational planning: long-range, or strategic

Nurse managers are more likely to be involved in the operational planning,

Strategic Planning Process